The natural history of scapholunate ligament injury is unknown. In fact, as far as we can tell, there has been no study examining the long-term natural history of this condition. It has, however, been assumed that the long-term progression of this injury leads to secondary osteoarthritis – scapholunate advanced collapse (the so-called SLAC wrist). In this study, we evaluated the clinical condition of 11 patients with proven scapholunate ligament injuries that had declined further treatment in an attempt to quantify any long-term disability. Whilst there was on-going pain and functional limitation in the injured wrist, there was no rapid progression of the osteoarthritis or SLAC wrist deformity

Introduction. Acute ankle injuries are commonly seen in musculoskeletal practice. Surgical management is the gold standard for lateral ligament injury in those with failed conservative treatment for a minimum of six months. Several studies have shown good functional outcome and early rehabilitation after MBG repair with an internal brace augmentation which is a braided ultrahigh molecular weight polyethylene ligament used to enhance the repair that acts as a secondary stabiliser. Hence the aim of the study was to compare the results with and without augmentation. Methods. A single centre retrospective review conducted between November 2017 and October 2019 and this included 172 patients with symptomatic chronic lateral ligament instability with failed conservative management. The diagnosis was confirmed by MRI. All patients had an ankle arthroscopy followed by open ligament repair. Patients were grouped into isolated MBG and internal brace groups for analyses and all had dedicated rehabilitation. Results. A total of 148 patients were available for final follow up with 87 patients in the MBG group and 61 patients in the IBA group. Mean Age was 38 years and mean follow up was 22 months. The internal brace group showed better Manchester Oxford foot and ankle score (19.7 vs 18.2) and more patients returning to preinjury activity levels (73 vs 55) as compared to isolated repair. Conclusion. Internal brace augmentation with MBG repair facilitated early rehabilitation and return to pre injury activity level in majority of patients compared to isolated MBG repair

Following ankle sprain, there can be many causes of disability including ligament injuries, soft tissue or bony impingement, Peroneal tendon tears, osteochondral defects (OCD), synovitis and Osteoarthritis (OA). Aim: To assess the use of Ankle MRI in clinical decision-making in patients with pain and/or chronic instability following ankle sprains. Method: A retrospective case note review was undertaken for all ankle scopes performed and all Ankle MRI ordered by a single surgeon (AOA) over a three-year period (April 2004 – April 2007). Results: During this period 54 Ankle arthroscopies were performed. 24 had pre op MRI scans (16 ordered by AOA and 8 by others who then referred the patient) and 30 had no MRI. 8 case notes were not available. In 43 of the 46 available notes the patients presented with either chronic ankle pain or instability following ankle sprain. 32 had Anterolateral soft tissue impingement on arthroscopy. Of these 24 had MRI scans with only 3 reporting a soft tissue impingement. 13 patients had lateral ligament reconstruction. All 13 of these patients showed signs of instability on examination under anaesthesia (EUA). Of these 9 had MRI scans with 4 reporting a ligamentous injury. Five other patients had MRI scans that showed a lateral ligament injury but had a normal EUA and did not undergo a ligament reconstruction. 10 patients had moderate to severe OA on arthroscopy of the ankle. Of these 4 had MRI scans with 2 reporting OA changes but 2 reported as OCD. Conclusion: Analysing the available data suggests that the indication to perform an arthroscopy is not dependent on the results of the MRI scan but is a clinical one. The decision to reconstruct/repair the lateral ligament complex is a clinical one dependent on patient symptom and the EUA findings

Objectives. The injured anterior cruciate ligament (ACL) is thought to exhibit an impaired healing response, and attempts at surgical repair have not been successful. Connective tissue growth factor (CTGF) is reported to be associated with wound healing, probably through transforming growth factor beta 1 (TGF-β1). Methods. A rabbit ACL injury model was used to study the effect of CTGF on ligament recovery. Quantitative real-time PCR (qRT-PCR) was performed for detection of changes in RNA levels of TGF-β1, type 1 collagen (COL1), type 2 collagen (COL2), SRY-related high mobility group-box gene9 (SOX9), tissue inhibitor of metalloproteinase-1 (TIMP-1) and matrix metallopeptidase 13 (MMP-13). Expression of related proteins was detected by Western blotting. Results. The current study showed that CTGF could promote the recovery of an injured anterior cruciate ligament. It can upregulate mRNA and expression of TGF-β1, COL1, COL2, SOX9, and tissue inhibitor of TIMP-1, and downregulate mRNA and expression of MMP-13, suggesting that the curative effect of CTGF on injured rabbit ligaments is through regulation of these cellular factors. Conclusions. This finding revealed the healing role of CTGF in injured tissues and provides new possibilities of treating injured tissues and wound healing by using CTGF. Cite this article: X. Sun, W. Liu, G. Cheng, X. Qu, H. Bi, Z. Cao, Q. Yu. The influence of connective tissue growth factor on rabbit ligament injury repair. Bone Joint Res 2017;6:399–404. DOI: 10.1302/2046-3758.67.BJR.2016-0255.R1

Chauffeur fractures or isolated radial styloid fractures (IRSF) are known to be associated with scapholunate ligament (SL) injuries. Diagnosis without arthroscopic confirmation is difficult in acute fractures. Acute management of this injury with early repair may prevent the need for more complex reconstructive procedures for chronic injuries. We investigated if all IRSF should be assessed arthroscopically for concomitant SL injuries.

We performed a prospective cohort study on patients above the age of 16, presenting to the Gold Coast University Hospital with an IRSF, over 2 years. Plain radiographs and computerized tomography (CT) scans were performed. All patients had a diagnostic wrist arthroscopy performed in addition to an internal fixation of the IRSF. Patients were followed up for at least 3 months post operatively. SL repair was performed for all Geissler Grade 3/4 injuries.

10 consecutive patients were included in the study. There was no radiographic evidence of SL injuries in all patients. SL injuries were identified arthroscopically in 60% of patients and one third of these required surgical stabilisation. There were no post operative complications associated with wrist arthroscopy.

We found that SL injuries occurred in 60% of IRSF and 20% of patients require surgical stabilisation. This finding is in line with the literature where SL injuries are reported in up to 40-80% of patients. Radiographic investigations were not reliable in predicting possible SL injuries in IRSF. However, no SL injuries were identified in undisplaced IRSF. In addition to identifying SL injuries, arthroscopy also aids in assisting and confirming the reduction of these intra-articular fractures.

In conclusion, we should have a high index of suspicion of SL injury in IRSF. Arthroscopic assisted fixation should be considered in all displaced IRSF. This is a safe additional procedure which may prevent missed SL injuries and their potential sequelae.

The anterolateral ligament (ALL) is considered as an important stabilizer of the knee joint. This ligament prevents anterolateral subluxation of the proximal tibia on the femur when the knee is flexed and internally rotated. Injury of the ALL was not investigated in patients with knee dislocation. The aim of the current research is to study the prevalence and characteristics of ALL injury in dislocated knees.

A retrospective review of charts and radiological images was done for patients who underwent multiligamentous knee reconstruction surgery for knee dislocation in our institution from May 2008 to December 2016. Magnetic resonance imaging (MRI) was used to describe the ALL injury. The association of ALL injury with other variables related to the injury and the patient's background features was examined.

Forty-eight patients (49 knees) were included. The mean age of the patients was 32.3 ± 10.6 years. High energy trauma was the mechanism of dislocation in 28 (57.1%) knees. Thirty-one knees (63.3%) were classified as knee dislocation (KD) type IV. Forty-five (91.8%) knees had a complete ALL injury and three (6.1%) knees had incomplete ALL injury. Forty (81.6%) knees had a complete ALL injury at the proximal fibres of the ALL, while 23 (46.9%) knees had complete distal ALL injury. None of the 46 (93.9%) knees with lateral collateral ligament (LCL) injury had normal proximal ALL fibres (p = 0.012). Injury to the distal fibres of the ALL, as well as overall ALL injury, were not associated with any other variables (p >0.05). Moreover, all patients with associated tibial plateau fractures (9, 18.4%) had abnormality of the proximal fibres of the ALL (p = 0.033).

High grade ALL injury is highly prevalent among dislocated knees. The outcomes of reconstructing the ALL in multiligamentous knee reconstruction surgery should be investigated in future studies.

Introduction and Objective

Forced external rotation is hypothesized as the key mechanism of syndesmotic ankle injuries. This complex trauma pattern ruptures the syndesmotic ligaments and induces a three-dimensional deviation from the normal distal tibiofibular joint configuration. However, current diagnostic imaging modalities are impeded by a two-dimensional assessment, without taking into account ligamentous stabilizers. Therefore, our aim is two-fold: (1) to construct an articulated statistical shape model of the normal ankle with inclusion of ligamentous morphometry and (2) to apply this model in the assessment of a clinical cohort of patients with syndesmotic ankle injuries.

Injuries to the lateral ligamentous complex of the ankle are common. The most commonly injured ligament is the anterior talofibular ligament (ATFL) followed by the calcaneofibular ligament (CFL). The posterior talofibular ligament (PTFL) is less commonly injured. There are few studies reporting the incidence of PTFL injury and less data available which describes the significance of this injury. We aim to establish an incidence of PTFL injury and allude to the possible significance of such an injury.

Purpose: We report a retrospective series of 28 patients with trauma-induced dislocation of the knee. The purpose of our study was to evaluated long-term outcome after orthopaedic as well as surgical management of these injured knees and to propose a therapeutic attitude best adapted to the initial situation.

Material and methods: The series included 28 patients, including one who had a bilateral dislocation. There were four women and 24 men, mean age 35.3 years at the time of the accident (17–69). Mean follow-up was 10.8 years. Nineteen knees were treated orthopaedically after reduction, surgery was used for ten patients. Five patients underwent an initial operation (during the first week following the accident), five had a secondary operation one to eight years after the accident. Mobility and laxity were assessed clinically. The Lysholm-Tegner and the Meyers scores were used to assess function. Radiological results were assessed with the Ahlback classification and the IKDC score to judge potential progression to single-or triple compartment osteoarthritis.

Results: Clinically, mean amplitude was 105° flexion and −2° extension. Four knees were stiff with flexion = 80°. There was a persistent anterior drawer sign for all knees except four. Medial laxity (valgus) was often important (83% of the patients). Functionally, the mean Lysholm score was 80.5 (17–100). The mean pre and post-trauma Tegner score was 5.1/3. The Meyes classification showed 15 good and excellent results and eight fair and six poor results. Radiographically, more than half the patients had no sign of degenerative joint disease and only four knees has signs of true three-compartment osteoarthritis according to the Ahlback classification. Separate analysis of patients treated orthopaedically and surgically showed that good results with orthopaedic treatment concerned patients with an anterior or posterior dislocation with predominantly anterior laxity. The fair and poor results concerned six of the eight patients with initially multidimensional laxity, particularly postero-lateral laxity that persisted at last follow-up. Surgical treatment gave good results mainly when given early (four very good results out of five knees).

Discussion: Recent work has demonstrated very satisfactory results for femorotibal stability after ligament reconstruction, usually with allografts. Our good functional results, comparable with earlier series, and the encouraging radiographic results have led us to chose orthopaedic treatment for selected patients (correct preservation of the posterolateral plane, particularly in case of dislocation with hyperextension corresponding to grade II in the Schenck classification), and on the contrary, to prefer early surgical treatment for the posterolateral plane.

Conclusion: Management of injury to knee ligaments after femorotibial dislocations should be guided by a precise examination of the initial laxities conducted under general anaesthesia. If the posteriolateral plane is satisfactory, orthopaedic treatment followed by active rehabilitation can provide good functional and radiographic results.

Stable Weber B fractures are typically treated non-operatively without complications but require close monitoring due to concerns over potential medial deltoid ligament injuries and the risk of delayed talar shift. Following recent evidence suggesting this is unlikely, a functional protocol with early weight bearing was introduced at Glasgow Royal Infirmary (GRI) following a pilot audit. This study aims to evaluate the risk of delayed talar shift in isolated Weber B fractures managed with functional bracing and early weight-bearing, particularly if signs of medial ligament injury are present. We conducted a retrospective review of 148 patients with isolated Weber B fractures without talar shift at presentation that were reviewed at the virtual fracture clinic at our institution between July 2019 and June 2020. The primary outcome was the incidence of delayed talar shift. Secondary outcomes were other complications and adherence to protocol. 48 patients had medial signs present and of these 1 (2%) showed possible talar shift on X-rays at 4 weeks, and was kept under review. This patient had a normal medial clear space at 3 months. No patients with medial signs not documented (n=19) or not present (n=81) had delayed talar shift. 10% of patients (n=15) had at least 1 complication: delayed union (n=2); non-union (n=3); ongoing pain (n=14). Functional bracing with early weight-bearing is a safe, effective protocol for managing isolated Weber B fractures without initial talar shift. This study concludes that the risk of delayed talar shift is low in all patients, with or without medial signs

One-fourth of all ankle trauma involve injury to the syndesmotic ankle complex, which may lead to syndesmotic instability and/or posttraumatic ankle osteoarthritis in the long term if left untreated. The diagnosis of these injuries still poses a deceitful challenge, as MRI scans lack physiologic weightbearing and plain weightbearing radiographs are subject to beam rotation and lack 3D information. Weightbearing cone-beam CT (WBCT) overcomes these challenges by imaging both ankles during bipedal stance, but ongoingdebate remains whether these should be taken under weightbearing conditions and/or during application of external rotation stress. The aim of this study is study therefore to compare both conditions in the assessment of syndesmotic ankle injuries using WBCT imaging combined with 3D measurement techniques. In this retrospective study, 21 patients with an acute ankle injury were analyzed using a WBCT. Patients with confirmed syndesmotic ligament injury on MRI were included, while fracture associated syndesmotic injuries were excluded. WBCT imaging was performed in weightbearing and combined weightbearing-external rotation. In the latter, the patient was asked to internally rotate the shin until pain (VAS>8/10) or a maximal range of motion was encountered. 3D models were developed from the CT slices, whereafter. The following 3D measurements were calculated using a custom-made Matlab® script; Anterior tibiofibular distance (AFTD), Alpha angle, posterior Tibiofibular distance (PFTD) and Talar rotation (TR) in comparison to the contralateral non-injured ankle. The difference in neutral-stressed Alpha angle and AFTD were significant between patients with a syndesmotic ankle lesion and contralateral control (P=0.046 and P=0.039, respectively). There was no significant difference in neutral-stressed PFTD and TR angle. Combined weightbearing-external rotation during CT scanning revealed an increased AFTD in patients with syndesmotic ligament injuries. Based on this study, application of external rotation during WBCT scans could enhance the diagnostic accuracy of subtle syndesmotic instability

Abstract. Objectives. Tendon and ligament injury poses an increasingly large burden to society. With surgical repair and grafting susceptible to high failure rates, tissue engineering provides novel avenues for treatment. This systematic review explores in vivo evidence whether mesenchymal stem cell-derived extracellular vesicles (MSC-EVs) can facilitate tendon and ligament repair in animal models. Methods. On May 26th 2021, a systematic search was performed on PubMed, Web of Science, Cochrane Library, Embase, using search terms ‘mesenchymal stem cell’ or ‘multipotent stem cell’ AND ‘extracellular vesicles’ or ‘exosomes’ AND ‘tendon’ or ‘ligament’ or ‘connective tissue’. Risk of bias was assessed using SYstematic Review Center for Laboratory animal Experimentation (SYRCLE) tool. Studies administering EVs isolated from human or animal-derived MSCs into in vivo models of tendon/ligament injury were included. In vitro, ex vivo, in silico studies were excluded, and studies without a control group were excluded. Data on isolation and characterisation of MSCs and EVs, and in vivo findings in animal models were extracted. Results. Out of 383 relevant studies, 11 case-control studies were included for data extraction, including a total of 448 animal subjects (range 10–90). Six studies utilised bone marrow-derived MSCs. All studies characterised their MSCs via flow cytometry, which expressed CD44 and CD90, and isolated EVs via ultracentrifugation (average diameter 125nm). Five studies utilised histological scoring systems, all of which reported a lower score with EV treatment, suggesting improved healing ability. Four studies reported increased anti-inflammatory cytokine expression (IL-10, TGF-β1); three studies reported decreased endogenous M1/M2 macrophage ratio with EV treatment. Eight studies reported increased maximum stiffness, breaking load, tensile strength in EV-treated tendons. Conclusion. MSC-EVs are effective therapeutic agents for tendon/ligament pathologies, attenuating the initial inflammatory response, and accelerating tendon matrix regeneration. Future randomised controlled trials are needed to definitely demonstrate MSC-EVs superiority in management of tendon/ligament injury

This study describes the introduction of a virtual pathway for the management of suspected scaphoid fractures and reports patient-reported outcome measures (PROMs) and satisfaction following treatment with this service. All adult patients that presented with a clinically suspected scaphoid fracture that was not visible on presentation radiographs over a one-year period were eligible for inclusion in the pathway. Demographics, examination findings, clinical scaphoid score (CSS) and standard four view radiographs were collected at presentation. All radiographs were reviewed virtually by a single consultant hand surgeon, with patient-initiated follow-up on request. PROMs were assessed at a minimum of one year post presentation and included the QuickDASH, EQ-5D-5L, the Net Promoter Score (NPS) and return to work. There were 221 patients referred to the virtual pathway. The mean age was 41 (range 16–87; SD 18.4 years) and there were 99 men (45%). There were 189 (86%) patients discharged with advice and 19 (9%) patients were recalled for clinical review (seven undisplaced scaphoid fractures, six other acute fractures of the hand or wrist, two scapholunate ligament injuries, and four cases where no abnormality was detected). Thirteen patients (6%) initiated follow-up with the hand service; no fracture or ligament injury was identified within this group. PROMs were available for 179 (81%) patients at a mean of 19 months follow-up (range: 13 – 33 months). The median QuickDASH score was 2.3 (IQR, 0–15.9), the median EQ-5D-5L was 0.85 (IQR, 0.73–1.00), the NPS was 76, and 173 (97%) patients were satisfied with their treatment. There were no documented cases of symptomatic non-union one year following injury. This study reports the introduction of a virtual pathway for suspected scaphoid fractures, demonstrating high levels of patient satisfaction, excellent PROMs, and no detrimental effects in the vast majority of cases

Abstract. Background. Fracture dislocation of the knee involves disruption of two or more knee ligaments with associated tibial plateau fracture. If these injuries are not evaluated swiftly, can result in a limb-threatening injury. The aim of this study is to look at the clinical outcomes of a single surgeon case series at a major trauma centre. Methods. Prospectively collected data was analysed for a 5-year period. Primary outcome measures used were International Knee Documented Committee(IKDC) score and Knee Injury & Osteoarthritis Outcome Score(KOOS). The secondary outcome measures include Tegner activity scale, knee range of movements & complications. Results. 23 patients were presented with the mean age was 37 years(17–74). 14% of patients sustained vascular injury & 19% had common peroneal nerve injury. Priority was given for early total repair/reconstruction with fracture fixation within 3 weeks where feasible (90% of patients), and if not, a staged approach was adopted. The mean IKDC score was 67 & KOOS was 73. The mean postoperative Tegner Activity Scale was 3.6 with mean flexion of 115(90–130). We observed some patterns of tibial plateau fractures are associated with similar patterns of ligamentous injuries. The anterio-medial rim fractures (52%) were associated with PCL, ACL & avulsion injuries of posterio-lateral corner structures. Most of the neurovascular injuries happened in this group. The other recognisable pattern was posterio-medial fractures, which were associated with ACL avulsion injury. Conclusion. To our knowledge, this is the first kind of study to report some fracture patterns that can be associated with particular ligamentous injuries

Patellar dislocation is a common presentation with a clear management pathway. Sometimes, however, what a patient experiences as the patella dislocating may, in fact, be ACL insufficiency. We reviewed case notes and imaging of 315 consecutive ACL reconstructions, collecting data on the date and mechanism of injury, time to MRI, and reconstruction. We noted cases initially diagnosed as patellar dislocation. 25 of 315 (7.9%) patients were initially diagnosed with a patellar dislocation. Subsequently, however, MRI scans revealed no evidence of patellar dislocation and instead showed ACL rupture with pathognomonic pivot-shift bony oedema. The false patella dislocation group were 32% female and had an average age of 25; the rest of the group average age was 27.1 and there were a lower proportion of females; 21%. The false patella instability patients had a median waiting time of 412 days from injury to operation (range: 70-2445 days), compared to 392 days (range: 9 – 4212 days) for rest of the patients. 5 of the remaining 290 had MRIs showing patella oedema with medial patello-femoral ligament injury in addition to their ACL rupture. From our literature search this is a new finding which shows that ACL rupture can present with symptoms suggestive of patellar dislocation. These findings raise the risk that there are a group of people who have been diagnosed with patellar instability who instead have ACL insufficiency and so are at risk of meniscal and chondral damage. Further research should analyse those diagnosed with patellar instability to quantify missed ACL injuries

Abstract. Introduction. The aim of this study was to determine if elite athletes could return to professional sport after MCL or PLC reconstruction using LARS ligaments and to demonstrate the safety and efficacy of LARS by reporting sport longevity, subsequent surgeries and complications. Methods. A retrospective review of all extra-articular knee ligament reconstructions in elite athletes utilising LARS ligaments by 3 knee surgeons between January 2013 and October 2020 was undertaken. Return to play (RTP) was defined as competing at professional level or national/ international level in amateur sport. Results. Sixty-four (84.2%) MCL and 12 (15.8%) PLC reconstructions utilising LARS in elite athletes were included. 52 (68.4%) underwent concomitant cruciate(s) reconstruction. The mean age was 25.1 years (SD +/− 4.50. Most were football (35, 46.1%) or rugby players (35, 46.1%). Sixty-seven athletes (88.2%) RTP with 65 (97.0%) of these playing at the same or higher Tegner level. 56 (83.6%) and 20 (57.1%) were still playing at 2 and 5 years post-surgery. Six (7.9%) players (5 of whom RTP) required further surgery relating to the LARS / metalwork and there was one case of adverse local inflammatory reaction to the synthetic material. There was one MCL re-rupture, sustained 4 years after RTP. Conclusion. Utilising LARS in extra-articular knee ligament reconstructions allows 88.2% of athletes, with a variety of knee ligament injuries, to return to elite sport. The low morbidity rates coupled with 57% of athletes still playing 5 years post-surgery suggests the LARS is safe and effective in these cases

Introduction. The treatment of posterior malleolar fractures is developing. Mason and Molloy (Foot Ankle Int. 2017 Nov;38(11):1229-1235) identified only 49% of posterior malleolar rotational pilon type fractures had syndesmotic instabilities. This was against general thinking that fixation of such a fragment would stabilize the syndesmosis. Methods. We examined 10 cadaveric lower limbs that had been preserved for dissection at the Human Anatomy and Resource Centre at Liverpool University in a solution of formaldehyde. The lower limbs were carefully dissected to identify the ligamentous structures on the posterior aspect of the ankle. To compare the size to the rotational pilon posterior malleolar fracture (Mason and Molloy 2A and B) we gathered information from our posterior malleolar fracture database. 3D CT imaging was analysed using our department PACS system. Results. The PITFL insertion on the posterior aspect of the tibia is very large. The average size of insertion was 54.9×47.1mm across the posterior aspect of the tibia. Medially the PITFL blends into the sheath of tibialis posterior and laterally into the peroneal tendon sheath. 78 posterior lateral and 35 posterior medial fragments were measured. On average, the lateral to medial size of the posteromalleolar fragment was 24.5mm in the posterolateral fragment, and 43mm if there is a posteromedial fragment present also. The average distal to proximal size of the posterolateral fragment was 24.5mm and 18.5mm for the posteromedial fragment. Conclusion. The PITFL insertion on the tibia is broad. In comparison to the average size of the posterior malleolar fragments, the PITFL insertion is significantly bigger. Therefore, for a posterior malleolar fracture to cause posterior syndesmotic instability, a ligamentous injury will also have to occur. This explains the finding by Mason and Molloy that only 49% of type 2 injuries had a syndesmotic injury on testing

Background. Supination-external rotation (SER) injuries make up 80% of all ankle fractures. SER stage 2 injuries (AITFL and Weber B) are considered stable. SER stage 3 injury includes disruption of the posterior malleolus (or PITFL). In SER stage 4 there is either medial malleolus fracture or deltoid injury too. SER 4 injuries have been considered unstable, requiring surgery. The deltoid ligament is a key component of ankle stability, but clinical tests to assess deltoid injury have low specificity. This study specifically investigates the role of the components of the deep deltoid ligament in SER ankle fractures. Aim. To investigate the effect of deep deltoid ligament injury on SER ankle fracture stability. Methods. Four matched pairs (8 specimens) were tested using a standardised protocol. Specimens were sequentially tested for stability when axially loaded with a custom rig with up to 750N. Specimens were tested with: ankle intact; lateral injury (AITFL and Weber B); additional posterior injury (PITFL); additional anterior deep deltoid; additional posterior deep deltoid; lateral side ORIF. Clinical photographs and radiographs were recorded. In addition, dynamic stress radiographs were performed after sectioning the deep deltoid and then after fracture fixation to assess tilt of the talus in eversion. Results. All specimens with an intact posterior deep deltoid ligament were stable when loaded and showed no talar tilt on dynamic assessment. Once the posterior deep deltoid ligament was sectioned there was instability in all specimens. Surgical stabilisation of the lateral side prevented talar shift but not talar tilt. Conclusion. If the posterior deep deltoid ligament is intact SER fractures may be managed without surgery in a plantigrade cast. Without immobilisation the talus may tilt, risking deltoid incompetence

Surfing has rapidly grown in popularity as the sport made its debut at the Tokyo 2020 Olympic Games. Surfing injuries are becoming more relevant with the globalisation and increasing risks of the sport, but despite this, little is known about surfing injuries or prevention strategies in either the competitive or recreational surfer. We reviewed the literature for the incidence, anatomical distribution, type and underlying mechanism of acute and overuse injuries, and discuss current preventative measures. Four online databases, including MEDLINE, PubMed, EMBASE and Cochrane Library were searched from inception to March 2020. This review finds that skin injuries represent the highest proportion of total injuries. Acute injuries most frequently affect the head, neck and face, followed by the lower limbs. Being struck by one's own board is the most common mechanism of injury. Surfers are injured at a frequency of 0.30–6.60 injuries per 1000 hours of surfing. Most prior studies are limited by small sample sizes, poor data collection methodology and geographical constraints. The scientific literature on surfing injuries under-represents overuse musculoskeletal injuries and the efficacy of prevention strategies for surfing-related overuse musculoskeletal injuries has not been studied. Injuries to the head and neck pose greater risks to a surfer's morbidity and mortality, yet there is no consensus on the management protocol of spinal injuries that occur in open water. Non-contact acute ligament injuries have increased as surfing manoeuvres have become more acrobatic, and overuse musculoskeletal injuries are highly correlated with paddling. Further research is needed to establish preventative measures for both acute and overuse surfing injuries and to ensure the increasing popularity of surfing is met with an improved understanding of sport risks and safety. Specifically, we recommend research be prioritised regarding the efficacy of training programmes to prevent surfing-related overuse musculoskeletal injuries

Chronic lateral ankle instability (CLAI) is treated operatively, whereas acute ligament injury is usually treated nonoperatively. Such treatments have been widely validated. Apoptosis is known to cause ligament degeneration; however, few reports have focused on the possible role of apoptosis in degeneration of ruptured lateral ankle ligaments. The aim of our study is to elucidate the apoptosis that occurs within anterior talofibular ligament (ATFL) to further validate current CLAI treatments by adducing molecular and cellular evidence. Between March 2019 and February 2021, 50 patients were prospectively enrolled in this study. Ruptured ATFL tissues were collected from 21 CLAI patients (group C) and 17 acute ankle fracture patients (group A). Apoptotic cells were counted using the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling (TUNEL) assay. Western blotting for caspases 3, 7, 8, and 9 and cytochrome c, was performed to explore intrinsic and extrinsic apoptotic pathways. Immunohistochemistry was used to detect caspases 3, 7, 8, and 9 and cytochrome c, in ligament vessel endothelial cells. More apoptotic cells were observed in group C than group A in TUNEL assay. Western blotting revealed that the apoptotic activities of group C ligaments were significantly higher than those of group A (all p < 0.001). Immunohistochemistry revealed increased expression of caspases 3, 7, 8, and 9, and cytochrome c, in group C compared to group A. The ATFL apoptotic activities of CLAI patients were significantly higher than those of acute ankle fracture patients, as revealed biochemically and histologically. Our data further validate current CLAI treatments from a molecular and cellular perspective. Efforts should be made to reverse or prevent ATFL apoptosis in CLAI patients