Introduction: Ankle fractures are common in trauma practice. Traditional teaching has been to use two screws for medial malleolar fixation to achieve better rotational control. However, the evidence for this is limited. This study compares the outcome following either one or two screws for medial malleolar fracture fixation. Materials and Methods: Retrospective analysis of case notes and x-rays of all medial malleolar fracture fixations performed between 2002 to 2007. Two groups were formed (group-I and group-II) depending upon the use of either one or two screws, respectively. Both groups were age and sex matched. Besides patient demographics, fracture pattern according to Dennis–Webber classification, orientation of the medial malleolar fracture, position of screw in relation to fracture, post-operative fracture displacement and union (bony and clinical) were assessed. Patients were also contacted to assess whether they had returned to their pre-injury level of activities. Results: There were total of 76 patients (group-I had 37 and group-II had 39 patients). The majority were females with age range between 19 and 84 years with involvement of the right ankle mostly. In group-I, 15 patients had bi-malleolar Dennis-Webber type B fractures, 9 had bi-malleolar Dennis-Webber type C and 10 had tri-malleolar fractures. 3 had uni-malleolar fracture. In group-II, 20 patients had bi-malleolar Dennis-Webber type B fractures, 9 had bi-malleolar Dennis-Webber type C fractures and there were 5 tri-malleolar fractures. 5 had uni-malleolar fracture. The fracture orientation in both the groups was mostly horizontal than oblique and the screw placement was at an angle to the fracture in the majority of cases in both of them. There was no significant difference between the two groups, in terms of clinical union, post-operative fracture displacement and return of patients to their pre-injury level of activity. Conclusion: Medial malleolar fractures can be efficiently fixed with one screw only, which does not increase the risk of post-operative fracture fragment displacement, compared to using two screws

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

This prospective randomised trial aimed to assess the superiority of internal fixation of well-reduced medial malleolar fractures (displacement □2mm) compared with non-fixation, following fibular stabilisation in patients undergoing surgical management of a closed unstable ankle fracture. A total of 154 adult patients with a bi- or trimalleolar fracture were recruited from a single centre. Open injuries and vertically unstable medial malleolar fractures were excluded. Following fibular stabilisation, patients were randomised intra-operatively on a 1:1 basis to fixation or non-fixation after satisfactory fluoroscopic fracture reduction was confirmed. The primary outcome was the Olerud Molander Ankle Score (OMAS) at 12 months post-randomisation. Complications were documented over the follow-up period. The baseline group demographics and injury characteristics were comparable. There were 144 patients reviewed at the primary outcome point (94%). The median OMAS was 80 (IQR, 60-90) in the fixation group vs. 72.5 (IQR, 55-90) in the non-fixation group (p=0.165). Complication rates were comparable, although significantly more patients (n=13, 20%) in the non-fixation group developed a radiographic non-union (p<0.001). The majority (n=8/13) were asymptomatic, with one patient requiring surgical reintervention. In the non-fixation group, a superior outcome was associated with an anatomical medial malleolar fracture reduction. Internal fixation is not superior to non-fixation of well-reduced medial malleolar fractures when managing unstable ankle fractures. However, one in five patients following non-fixation developed a radiographic non-union and whilst the re-intervention rate to manage this was low, the longer-term consequences of this are unknown. The results of this trial may support selective non-fixation of anatomically reduced fractures

Background. Ankle fractures represent an increasing workload, particularly in the elderly female population. The posterior tibial tendon is exposed to injury during displaced medial malleolar fractures. Posterior tibial tendon dysfunction delays rehabilitation and results in significant morbidity and is most prevalent in women over 40. Objective. To ascertain whether posterior tibial tendon should be routinely explored in displaced medial malleolar fractures and consequently should post-operative rehabilitation of ankle fractures be modified. Intra-operative assessment of the tendon may help with this diagnosis and consequently alter post-operative rehabilitation. Method. We performed a prospective case series of 25 patients with displaced medial malleolar ankle fractures admitted to the Royal Victoria Hospital Belfast between August and November 2009. The admission notes were then checked for any previous injuries and the initial reduction was assessed radiologically. At the time of surgery the primary operator explored the posterior tibial tendon and assessed the tendon for damage using the following scale: nil, bruising, superficial, partial tear, complete tear. Results. The average age was 58. The majority of injuries were Weber B (20/25), bimalleolar (19/25), had an initial satisfactory reduction (19/25) and had the surgery performed by SPR/STR (22/25). The mechanism of injury was reported as mainly supination-external rotation (13/25). Eight patients were reported as having superficial damage and one with a partial rupture. Of note all patients included under the age of forty were reported as having no damage to posterior tibial tendon. Conclusion. This study does not support the routine exploration of the posterior tibial tendon in displaced medial malleolar fractures. However, the study would advocate an altered post-op regime for at risk groups for posterior tibial dysfunction

Introduction. Unstable ankle fractures are routinely managed operatively. Due to soft-tissue and implant related complications, there has been recent literature reporting on the non-operative management of well-reduced medial malleolus fractures following fibular stabilisation, but with limited evidence supporting routine application. This trial assessed the superiority of internal fixation of well-reduced (displacement ≤2mm) medial malleolus fractures compared with non-fixation following fibular stabilisation. Methods and participants. Superiority, pragmatic, parallel, prospective randomised clinical trial conducted over a four year period. A total of 154 adult patients with a bi- or trimalleolar fractures were recruited from a single centre. Open injuries and vertical medial malleolar fractures were excluded. Following fibular stabilisation, patients were randomised intra-operatively on a 1:1 basis to fixation or non-fixation after satisfactory fluoroscopic fracture reduction was confirmed. The primary outcome was the Olerud Molander Ankle Score (OMAS) at one-year post-randomisation. Complications and radiographic outcomes were documented over the follow-up period. Results. Among 154 participants (mean age, 56.5 years; 119 women [77%]), 144 [94%] completed the trial. At one-year the median OMAS was 80 (IQR, 60–90) in the fixation group compared with 72.5 (IQR, 55–90) in the non-fixation group (p=0.17). Complication rates were comparable. Significantly more patients in the non-fixation group developed a radiographic non-union (20% vs 0%; p<0.001), with the majority (n=8/13) clinically asymptomatic and one patient required surgical re-intervention for this. Fracture type and reduction quality appeared to influence fracture union and patient outcome. Conclusions. In this randomised clinical trial comparing internal fixation of well-reduced medial malleolus fractures with non-fixation, following fibular stabilisation, fixation was not superior according to the primary outcome. However, 1 in 5 patients following non-fixation developed a radiographic non-union and whilst the re-intervention rate to manage this was low, the future implications require surveillance. These results may support selective non-fixation of anatomically reduced medial malleolus fractures

Introduction. Deltoid ligament reconstruction (DLR) is an important factor in the consideration of pes planus deformity. There is little evidence in the literature determining whether DLR could mitigate the risk of patients acquiring flat foot postoperatively following deltoid ligament injury. Aim. Our objective was to establish if there was a difference in pes planus deformity in patients who underwent DLR during their ankle fracture fixation compared to those who did not. Methods. A retrospective analysis of post-operative weight bearing radiographs was performed of patients who underwent ankle fracture fixation. Inclusion criteria were confirmed deltoid instability presurgery without medial malleolar fracture and post operative weightbearing radiographs at least 6 weeks post-fixation. Patients were categorised into no deltoid ligament reconstruction (nDLR) and having DLR. Radiographic pes planus parameters involved Meary's Angle assessment. Other fracture morphology was classified. Results. A total 723 ankle fractures were screened. 122 patients were included for further analysis. There were 94 patients in the nDLR group and 28 patients in DLR group. The mean Meary's Angle was 15.81 (95% CI 14.06, 17.56) degrees in the nDLR group and −.2 (95% CI −3.86, 3.82) in the DLR group. This was statistically significant (p<.001). There was no significant difference in medial clear space measurements (2.90mm v 3.19mm, p = 0.145). There were significantly more pes planus patients in the nDLR than the DLR group (p<.001, 90.5% vs 25%). Conclusion. In this study there was significantly greater pes planus parameters in patients not undergoing DLR. Patients undergoing DLR had on average normal parameters, whilst those not undergoing DLR had on average severe pes planus. The benefits of DLR are not only maintaining ankle stability but maintaining medial arch integrity, and this should be taken into account in a future study on DLR

Introduction. A significant burden of disease exists with respect to critical sized bone defects; outcomes are unpredictable and often poor. There is no absolute agreement on what constitutes a “critically-sized” bone defect however it is widely considered as one that would not heal spontaneously despite surgical stabilisation, thus requiring re-operation. The aetiology of such defects is varied. High-energy trauma with soft tissue loss and periosteal stripping, bone infection and tumour resection all require extensive debridement and the critical-sized defects generated require careful consideration and strategic management. Current management practice of these defects lacks consensus. Existing literature tells us that tibial defects 25mm or great have a poor natural history; however, there is no universally agreed management strategy and there remains a significant evidence gap. Drawing its origins from musculoskeletal oncology, the Capanna technique describes a hybrid mode of reconstruction. Mass allograft is combined with a vascularised fibula autograft, allowing the patient to benefit from the favourable characteristics of two popular reconstruction techniques. Allograft confers initial mechanical stability with autograft contributing osteogenic, inductive and conductive capacity to encourage union. Secondarily its inherent vascularity affords the construct the ability to withstand deleterious effects of stressors such as infection that may threaten union. The strengths of this hybrid construct we believe can be used within the context of critical-sized bone defects within tibial trauma to the same success as seen within tumour reconstruction. Methodology. Utilising the Capanna technique in trauma requires modification to the original procedure. In tumour surgery pre-operative cross-sectional imaging is a pre-requisite. This allows surgeons to assess margins, plan resections and order allograft to match the defect. In trauma this is not possible. We therefore propose a two-stage approach to address critical-sized tibial defects in open fractures. After initial debridement, external fixation and soft tissue management via a combined orthoplastics approach, CT imaging is performed to assess the defect geometry, with a polymethylmethacrylate (PMMA) spacer placed at index procedure to maintain soft tissue tension, alignment and deliver local antibiotics. Once comfortable that no further debridement is required and the risk of infection is appropriate then 3D printing technology can be used to mill custom jigs. Appropriate tibial allograft is ordered based on CT measurements. A pedicled fibula graft is raised through a lateral approach. The peroneal vessels are mobilised to the tibioperoneal trunk and passed medially into the bone void. The cadaveric bone is prepared using the custom jig on the back table and posterolateral troughs made to allow insertion of the fibula, permitting some hypertrophic expansion. A separate medial incision allows attachment of the custom jig to host tibia allowing for reciprocal cuts to match the allograft. The fibula is implanted into the allograft, ensuring nil tension on the pedicle and, after docking the graft, the hybrid construct is secured with multi-planar locking plates to provide rotational stability. The medial window allows plate placement safely away from the vascular pedicle. Results. We present a 50-year-old healthy male with a Gustilo & Anderson 3B proximal tibial fracture, open posteromedially with associated shear fragment, treated using the Capanna technique. Presenting following a fall climbing additional injuries included a closed ipsilateral calcaneal and medial malleolar fracture, both treated operatively. Our patient underwent reconstruction of his tibia with the above staged technique. Two debridements were carried out due to a 48-hour delay in presentation due to remote geographical location of recovery. Debridements were carried out in accordance with BOAST guidelines; a spanning knee external fixator applied and a small area of skin loss on the proximal medial calf reconstructed with a split thickness skin graft. A revision cement spacer was inserted into the metaphyseal defect measuring 84mm. At definitive surgery the external fixator was removed and graft fixation was extended to include the intra-articular fragments. No intra-operative complications were encountered during surgeries. The patient returned to theatre on day 13 with a medial sided haematoma. 20ml of haemoserous fluid was evacuated, a DAIR procedure performed and antibiotic-loaded bioceramics applied locally. Samples grew Staphylococcus aureus and antibiotic treatment was rationalised to Co-Trimoxazole 960mg BD and Rifampicin 450mg BD. The patient has completed a six-week course of Rifampicin and continues on suppressive Co-Trimoxazole monotherapy until planned metalwork removal. There is no evidence of ongoing active infection and radiological evidence of early union. The patient is independently walking four miles to the gym daily and we believe, thus far, despite accepted complications, we have demonstrated a relative early success. Conclusions. A variety of techniques exist for the management of critical-sized bone defects within the tibia. All of these come with a variety of drawbacks and limitations. Whilst acceptance of a limb length discrepancy is one option, intercalary defects of greater than 5 to 7cm typically require reconstruction. In patients in whom fine wire fixators and distraction osteogenesis are deemed inappropriate, or are unwilling to tolerate the frequent re-operations and potential donor site morbidity of the Masqualet technique, the Capanna technique offers a novel solution. Through using tibial allograft to address the size mismatch between vascularised fibula and tibia, the possible complication of fatigue fracture of an isolated fibula autograft is potentially avoidable in patients who have high functional demands. The Capanna technique has demonstrated satisfactory results within tumour reconstruction. Papers report that by combining the structural strength of allograft with the osteoconductive and osteoinductive properties of a vascularised autograft that limb salvage rates of greater than 80% and union rates of greater than 90% are achievable. If these results can indeed be replicated in the management of critical-sized bone defects in tibial trauma we potentially have a treatment strategy that can excel over the more widely practiced current techniques

Background: Over many years our understanding of fracture patterns and management has evolved. One of the biggest steps was the adoption of the principles of fracture fixation as described by the Arbitsgemeinschaft fur Osteosynthesefragen (AO). The application of this philosophy has allowed us to optimise fracture management and improve outcome. In our unit we noted a number of complications resulting from suboptimal fracture fixations of ankles some of which required revision. It was decided to review fracture fixation of ankles in the unit to see whether the basic principles of fixation was being followed in our DGH. Aim: To evaluate whether the AO principles of fixation for ankle fractures are being followed in our local unit. Patients and Methods: 52 consecutive patients over a period of 1 year from August 2005 to August 2006 with bi malleolar and isolated medial malleolar ankle fractures, requiring surgery, had their case notes and pre operative x rays reviewed retrospectively looking at fracture patterns according to the AO and Weber classification. Post operative x rays where reviewed to see if the principles of facture fixation had been appropriately followed. Results: Of the 52 patients evaluated 26 were Weber type B fractures, 20 were type C and 6 were isolated medial malleolar fracture. Nine of the type B and three of type C (23% of the total number) underwent fixation not in accordance with AO principles. In every case the fibula fixation did not include a cortical lag screw. Discussion/Conclusions: Although none of the 12 described had to undergo revision, their management was far from optimum. By ensuring that operating surgeons have the appropriate training and experience in basic fracture fixation before being allowed to undertake such procedures, our unit hopes to show an improvement on these figures by the time this audit is repeated

Recently with the introduction of operations using various instrument of total ankle arthroplasty, we are showing quite satisfactory short term results on the treatment of resolved pain of ankle joint. However, there have been reports of high probability of complication from total ankle arthroplasty to other arthroplasty applied to other joints. Therefore in order to make the results of ankle arthroplasty superior, it is necessary to reduce these complications. We try to analyze complications that occur often and come up with the best results. There were 45 cases of 42 patients of HINTEGRA. ®. (Newdeal SA, Lyon, France) model from November 2004 to August 2006. Follow up averaged 33.5 months, the average age of patients was 61.1 years, with 14 males and 28 females. We evaluated the complications and analyzed the causes of failures. There was a total 15 cases of complications; 5 cases of medical impingement syndrome, 3 cases of varus malposition, 2 cases of delayed healing of wound, 1 case of peroneal nerve problem, medial malleolar fracture, postoperative deep infection and gouty arthritis pain and Achilles tendinitis. Our conclusion is that total ankle arthroplasty had more complication rate than other joint arthroplasty, so we need a more meticulous preoperative and perioperative care

Introduction. Total ankle replacement (TAR) surgery remains a reasonable alternative to arthrodesis in a select group of patients with end stage ankle joint arthritis. We describe the early results of a prospective study of the first 50 Zenith total ankle replacements performed by a single surgeon (SKG). Methods. Demographic details, Visual Analogue Score (VAS) for pain (0, no pain; 10, worst possible pain), AOFAS scores, ‘would have surgery again’ and satisfaction levels were collated, pre-operatively and at their most recent outpatient review. Any post-operative complications were noted. Radiographs were also assessed for evidence of loosening, progressive osteolysis, subsidence and overall alignment of the implant. Results. One patient died at 25 months following surgery from unrelated causes. No patients have been lost to follow up. A review of 50 patients (35 males, 15 females; mean age 65 years, range 44–88 years) with a mean follow up of 30 months (range 11–48) included 48 patients with osteoarthritis and two patients with rheumatoid arthritis. There was one medial malleolar fracture at the time of surgery which required fixation and one fracture of the lateral malleolus which was picked up at the six week review. At their latest review the VAS and AOFAS score had improved significantly and 46 patients were satisfied and 4 patients unsatisfied with the outcome of surgery. One patient has cyst formation around the tibial component but is pain free with a stable implant and does not wish further intervention. The components were satisfactorily aligned in the vast majority of patients. Conclusion. This non-inventor series of the Zenith TAR has shown excellent results in the short term. We feel that the instrumentation allows for more reproducible cuts which appear to be technically easier than with some other designs. However, studies looking at long term results will be necessary

Introduction. Surgeons, commissioners and patients are increasingly seeking more in depth details on outcomes of total ankle replacement (TAR). We set out to perform a detailed and up to date meta-analysis of the outcomes of TAR, with a focus on PROMS. Methods. We searched MEDLINE, Cochrane, EMBASE, CINAHL and the Science Citation Index databases using the terms “total”; “ankle”; “arthroplasty” or “replacement” to April 2012. We included all languages; series with greater than 20 TAR; minimum 2 years follow-up. We excluded papers on revisions; prostheses no longer marketed; and kin studies. We worked with the Cochrane Collaboration to adopt their methodology including the creation of a risk profile assessing all forms of bias. Results. Of 1841 papers identified, 51 remained for analysis, with a pool of 6719 patients. The mean patient age was 59.3(17–95) and mean BMI was 28.8(19.4–44). 53% of patients were male. The most common indication was posttraumatic osteoarthritis. The majority of the studies were level IV and more than half the studies had several forms of bias. Intraoperative complication rate was 9%, with medial malleolar fracture (4.4%) being the most common. The pooled mean pre-op VAS was 7.6 which improved to 1.5 at 4–5 years. The mean pre-op AOFAS was 39.7, improving to 79.9 for up-to 10 years. Range-of-motion increased after TAR from 22.8° preoperatively to 33.6° postoperatively. Radiographic abnormalities were found in 22% of cases with a mean follow up of 53 months, of which 7.9% were re-operated upon. Gait velocity, cadence, stride length and power all improve following TAR. Survival at 8–10 years was 89.4%, with a cumulative failure rate of 1.9%. Conclusion. This is the most comprehensive meta-analysis carried out on TAR to date. TAR provides patients with an increased range of motion and improvement postoperative PROMS maintained up to 10 years

Introduction:. The aim of this study was to identify the rate of complications of total ankle replacement in a single Centre to help with informed patient consent. Methods:. Between 2008 and 2012, 202 total ankle replacements (TARs) were performed by 4 surgeons at our Institute. Data was collected on all patients; demographics, arthritic disease, pre-operative deformity, prosthesis and all early and late complications. Results:. 4 surgeons (A, B, C, D) performed 63, 55, 48 and 36 TARs (178 De Puy Mobility and 24 Corin Zenith). 130 patients had primary osteoarthrosis, 35 had rheumatoid and 36 had post traumatic osteoarthrosis. There were no differences in patient demographics for each surgeon. There were 3 deep infections (A, B, C, D: 1,0,2,0). There were 18 medial malleolar fractures (8 intra-operative [4,1,1,2], 3 early (< 3 months) [1,1,0,1] and 7 late (> 3 months) [2,2,2,1]). There were 2 lateral malleolar fractures, both intra-operative (0,0,1,1). There were 15 patients who developed superficial wound infections, which resolved fully with oral antibiotics (4,3,4,4). A further 7 patients had a delay to wound healing (wound not fully healed at 3 months) (4,0,2,1); 2 of these developed deep infection and failed. 22 patients had persistent medial gutter pain (9,4,5,4); all had undergone Mobility TAR. 4 patients developed recurrent edge loading and have had to be revised (4 converted to TTC fusion) (2,0,2,0). We report complications in 32% of patients. Overall 9 TARs failed and underwent revision to fusion (2,2,5,0). Conclusion:. We report an overall complication rate of 32% following TARs, however most are minor and don't affect clinical outcome. We had a 1.5% deep infection rate. Complication rates were comparable between 4 surgeons. There was a difference in medial gutter pain rate between implants (13% v 0% Mobility to Zenith). This data provides detailed complication rates for informed consent

Advances in implant design and instrumentation have led to total ankle replacement (TAR) becoming an attractive alternative to ankle fusion in selected cases. We present the short-term results for Mobility TAR with clinical and radiological findings. Methods: Prospective study from Dec 2004 to Dec 2007. Single surgeon, anterior approach to the ankle. Patients assessed clinically, radiologically and with pre and postoperative visual analogue (VAS) and American orthopaedic foot and ankle society (AOFAS) hindfoot score. Results: 34 patients, 36 TAR, 2 bilateral. Male 25, female nine. Mean age 66.9 years, range 43 to 89 years. 26 osteoarthritis, four rheumatoid arthritis, four post-traumatic osteoarthritis. Follow up 6 months to 3.5 yrs, mean 22 months. VAS pre-operative mean 8, postoperative mean 1.5. AOFAS score mean pre-operative 30, post-operative mean 85. No deep infections, 3 superficial infections, which settled with antibiotics. No nerve damage. Two medial malleolar fractures. Two lateral malleolar fractures. One talar malposition – one of first six cases, no surgery required outcome not affected. Three unexplained painful TAR. No revisions. 90% patients satisfied and would have operation again. Conclusion: Short-term results for TAR are encouraging. Implants and instrumentation are improving and patients are satisfied with the results. There is a steep learning curve of at least six cases. Surgical skill, technique and careful patient selection are paramount in achieving satisfactory results. With patient demands increasing TAR is a realistic alternative to ankle fusion

The Mobility (DePuy International) is a three-component, cobalt chrome, uncemented design. Patients. Over an 18-month period 100 ankles, with end-stage arthritis and less than 20 degree valgus or varus deformity, were replaced. There were 95 patients (70 OA, 25 RA) with average age of 65 years (41-95). Five had bilateral replacements. Follow-up was 30 months (24 to 48). Results. Average score on VAS pain line improved from 8.8 to 1.8. The average AOFAS pain score improved from 3 to 33. Average AOFAS function score improved from 31 to 48. Four patients were disappointed because pain relief was poor. Four ankles have undergone further surgery. One ankle was converted to fusion for recurrent deformity. One ankle required repeated washout for infection at six months but remains clinically and radiologically satisfactory 2 years later. One ankle required exchange of UHMWP insert at 4 weeks because of a technical error. One ankle required fixation of an ununited intraoperative medial malleolar fracture and subsequently developed ‘edge loading’, namely radiographs showed that a gap had opened up between the articular surfaces on the lateral side of the joint. The radiographs of 3 other ankles also showed ‘edge loading’. Two of these patients were symptom free but one wore a brace to control symptoms of instability. Radiographs showed bony incorporation in all surviving ankles. This was always complete around the tibial stem and under the talar component. However in 15 ankles there was a small non-progressive area of lucency adjacent to the tibial plate. Conclusion. These early results are encouraging and an improvement on those previously reported by the same surgeon using other designs. We believe that this is attributable to the ongoing process of refining the indications and improving surgical technique and implant design

Aims: Outcome of the distal tibial fractures treated with interlocking nail. Method: We reviewed 108 patients with distal tibial fractures which were treated in our clinic between 1990 using interlocking intramedullary nailing. 94 patients (63 men and 31 women) were found in the recent follow up. AO fracture classiþcation system was used Seventy-eight patients had concomitant fractures of the lateral malleolar and 4 had medial malleolar fractures. Eight (8,5%) of the fractures were open grade I. All fractures were managed with closed reamed nailing. In fourteen cases the nail had to be shortened. The lateral malleolar fractures were þxed before tibial nailing to ensure overall alignment. Results: Union was achieved in 89 (94,6%) fractures with a mean time of union of 4,2 months (range:3–10 months). One deep infection (1,06%) lead to nonunion. Three aseptic cases had delay union which required nail dynamization. In one more nonunion case bone grafting and þbulectomy required. Postoperative transient peroneal palsy occurred in 2 (2,12%) patients which were fully recovered. One patient developed deep posterior compartment syndrome leading to FHL conctracture, needed tendon lengthening. Conclusions: Interlocking intramedullary nailing is a reliable, safe and effective method of managing distal tibial fractures with or without minimal ankle joint involvement

We aim to assess the long term functional and symptomatic outcome of patients after open reduction internal fixation (ORIF) of the ankle. A retrospective telephone interview of patients (n=113) in years five, six and seven after ORIF of the ankle was conducted. The Olerud-Molander Ankle Score (scale 0–100) and SF-12 Health Survey scores were utilised to assess symptomatic and functional outcome. Fractures were classified in accordance with the Danis-Weber system. All patients were operated upon in the same unit by the same group of surgeons. Sixty five patients were male and 48 female. The mean age was 56 (range 15–96). Patients with Weber B fractures (n=83) had a mean OMAS of 89.2. Those with Weber C fractures (n=25) had a mean OMAS of 85.4. Five patients had isolated medial malleolar fractures. At five to seven years post-operatively, 67.3% of patients were symptomatic. Of these, 75% complained of swelling; 39% of pain and 30% of stiffness whilst 19.5% of all patients felt they had not returned to their pre-operative functional level. Regardless of fracture type or follow up time, patients under 40 years old, had a significantly higher mean OMAS (90.7) as compared to those between 40 and 65 years old (85.3) (p=0.024). There was no significant difference in the mean OMAS of patients followed up at five or seven years post operatively or between those with Weber B or C fractures. Patients suffer ongoing symptomatic and functional problems up to seven years after ORIF of the ankle and a significant number do not return to their pre-injury functional state. Patients under 40 years old had a better outcome as compared to older patients, whilst Weber type or year of follow up did not affect outcome. Surgeons should counsel patients pre-operatively regarding possible long term problems when undertaking ankle fracture fixation

Summary. Syndesmotic malreduction or failure to restore fibular length are the leading causes for early reoperation after ankle fracture surgery. Anatomic fracture reduction and congruent ankle mortise can be achieved in the majority of cases following revision surgery. Introduction. The goal of ankle fracture surgery is to restore anatomical congruity. However, anatomic reduction is not always achieved, and residual talar displacement and postoperative malreduction predispose a patient to post-traumatic arthritis and poor functional outcomes. The present study aimed to determine the most common surgical errors resulting in early reoperation following ankle fracture surgery. Patients & Methods. We performed a chart review to determine the most common types of malreductions that led to reoperation within the first week following ankle fracture surgery. From 2002 to 2011, we identified 5123 consecutive ankle fracture operations in 5071 patients. 79 patients (1.6%) were reoperated on due to malreduction (residual fracture displacement > 2mm) detected in postoperative radiographs. These patients were compared with an equal number of age- and sex-matched control patients. Surgical errors were classified according to the anatomical site of malreduction: fibula, medial malleolus, posterior malleolus, Chaput-Tillaux fragment, and syndesmosis. Problems related to syndesmotic reduction or fixation were further divided into four categories: malreduction of the fibula in the tibiofibular incisura due to malpositioning of a syndesmotic screw, persistent tibiofibular widening (TFCS > 6 mm), positioning of a syndesmotic screw posterior to the posterior margin of the tibia, and unnecessary use of a syndesmotic screw. Results. The mean patient age was 44 years (18 to 80), and 49% were women. There were no differences between the groups regarding diabetes, tobacco use, peripheral vascular disease, or alcohol abuse. The most common indication for reoperation was syndesmotic malreduction (47 of 79 patients; 59%). Other frequent indications for reoperation were fibular shortening and malreduction of the medial malleolus. We identified four main types of errors related to syndesmotic reduction or fixation, the most common being fibular malreduction in the tibiofibular incisura. The most commonly combined errors were malreductions of the fibula and syndesmosis, which occurred together in 16 of 79 patients (20%). Fracture-dislocation (p = 0.011), fracture type (p = 0.001), posterior malleolar fracture (p = 0.005), associated medial malleolar fracture (p = 0.001), duration of index surgery (p = 0.001), and associated medial malleolar fixation other than with two parallel screws (p = 0.045) were associated with reoperation. Correction of the malreduction was achieved in 84% of reoperated cases. Conclusion. Early reoperation after ankle fracture surgery was most commonly caused by errors related to syndesmotic reduction or failure to restore fibular length. In the majority of cases, postoperative malreduction was successfully corrected in the acute setting

Material: 100 consecutively performed Total Ankle Arthroplasties (TAA) of the Mobility design carried out at Schultess Clinic Zurich and 100 from Wrightington Hospital Wigan were entered into the study. The male: female ratio was 1:1. Age 62 (range 24 to 95 years). The diagnosis was primary OA (59%), OA resulting from a major injury in the past (20%) and rheumatoid arthritis (21%). We considered more than 20 degrees varus or valgus to be a contraindication to TAA. Methods: The Mobility TAA is three component, cobalt chrome uncemented design. The tibial component has a stem and the talar component has two fins for secure bony incorporation. At the time of TAA ancillary procedures such as gastrocnemius lengthening were performed if required. Results: The follow-up was 36 months (24 to 50). The most frequently performed ancillary procedure was gastro-soleus lengthening and this was carried out in 20% of cases. Osteotomy of os calcis and talo-navicular or other hindfoot fusion was performed in approximately 8%. The severity of pain was measured on the visual analogue scale before and at follow-up and this improved from 8.5 to 1.6. The average range of motion measured radiographically improved from 25 deg to 30 deg. The most frequent persistent complaint was that of occasional troublesome antero-medial pain. 92% patients were satisfied with the outcome. Complications were 6% intra-operative malleolar fractures. These did not lead to long term problems. Delayed wound healing occurred in 4% but all healed fully by three months. Late medial malleolar fractures occurred in 2%. Early infection occurred in one patient and was successfully treated by washout and antibiotics. Revision to fusion or change of tibilal and/or talar implant was required in 2.5% (5 patients) due to aseptic loosening and a technical error in one further patient treated three years ago led to subluxation of the insert. This was changed for an 11mm insert with a successful outcome to present time. Conclusion: These results are an improvement on those acheived by the same surgeons prior to this study using other types of implant. We believe this is due to improved instrumentation and implant design and a better understanding of the indications particularly the need to be very cautious in recommending replacement to patients with severe varus or valgus deformities

Aims

Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis.

Talar neck fractures are rare injuries representing only 0.14%–0.32% of all fractures, one in five of these is open. In order to investigate the hypothesis that open talar neck fractures have worse outcome than closed ones, we did a Metaanalysis of the literature. Manuscripts dealing with fractures of the talus were identified from a Pubmed search including databases from 1970 to 2004. The searches were made using the keywords talar fractures, fractures of the neck of talus, outcome of talar fractures and open talar fractures. Full articles were retrieved and methodological quality filters applied for their suitability for inclusion in a more detailed review. Data were extracted from these articles and methodology and outcome were analyzed. We analyzed the numbers of patients, numbers of open fractures, mechanism of injury, associated injuries, classification used, treatment methods, complications and outcome. Of 29 manuscripts reviewed, 22 met the inclusion criteria. These were subjected to more detailed analysis, the outcomes of 1017 patients were described. The commonest mechanism of injury was road traffic accidents (42%). The incidence of Hawkins’ types was type I 27%, type II 35%, type III 30% and type IV 8%. More than half the patients were treated by open reduction and internal fixation. Medial malleolar fracture was the most common associated injury. The overall incidence of avuscular necrosis was 30%. 23% developed ankle osteoarthritis, 34% subtalar and 7.5% both. 17 % of all patients have had one form of arthrodesis. 22% were open injuries and only few authors reported the detailed treatment and outcome of their open fractures, however infection rate was higher in open injuries and they tend to be associated more with type III and IV Hawkins’ classification. The fate of the extruded talus remains controversial. In conclusion, it appears that the current literature is poor in providing evidence based medicine in the management and outcome of open talar neck fractures. More detailed studies should be done to shed more light on the fate of these rare and disabling injuries