We present the case of a 19-year-old woman who sustained a right talar neck fracture when the car in which she was travelling was involved in a high-speed collision. She was a front seat passenger travelling with her feet up on the dashboard, and was injured when the passenger airbag deployed. Front airbags are designed to provide protection from impact injury by having the occupant “fall” into the already-inflated device, and in order to inflate quickly enough they rely on an explosive exothermic reaction. It is postulated that an inflating airbag has similar properties to a blast wave produced by an explosion, and thus if a person is in direct contact with an inflating rather than inflated airbag, they may sustain high energy transfer injuries, not dissimilar to blast wave injuries. Although airbags have undoubtedly lead to safer motoring, it is well known that they can cause serious injury in normal usage, and injuries to the face, neck, chest and abdomen have been well documented. They should not be thought of as entirely benign devices

Treatment of posterior malleolar (PM) ankle fractures remain controversial. Despite increasing recommendation for small PM fragment fixation, high quality evidence demonstrating improved clinical outcomes over the unfixated PM is limited. We describe the medium-to-long term clinical and radiographical outcomes in younger adult patients with PM ankle fractures managed without PM fragment fixation. A retrospective cohort study of patients aged 18–55 years old admitted under our orthopaedic unit between 1st of April 2009 and 31st of October 2013 with PM ankle fractures was performed. Inclusion criteria were that all patients must mobilise independently pre-trauma, have no pre-existing ankle pathologies, and had satisfactory bimalleolar and syndesmotic stabilisation. Open fractures, talar fractures, calcaneal fractures, pilon fractures, subsequent re-injury and major complications were excluded. All PM fragments were unfixated. Clinical outcomes were evaluated using Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sports subscale, visual analogue scale (VAS) and patient satisfaction ratings. Osteoarthrosis was assessed using modified Kellgren-Lawrence scale on updated weightbearing ankle radiographs. 61 participants were included. Mean follow-up was 10.26 years. Average PM size was 16.19±7.39%. All participants were evaluated for clinical outcomes, demonstrating good functional outcomes (FAAM-ADL 95.48±7.13; FAAM-Sports 86.39±15.52) and patient satisfaction (86.16±14.42%), with minimal pain (VAS 1.13±1.65). Radiographical outcomes were evaluated in 52 participants, showing no-to-minimal osteoarthrosis in 36/52 (69.23%), mild osteoarthrosis in 14/52 (26.92%) and moderate osteoarthrosis in 2/52 (3.85%). Clinical outcomes were not associated with PM fragment size, post-reduction step-off, dislocation, malleoli fractured or syndesmotic injury. PM step-off and dislocation were associated with worse radiographical osteoarthrosis. Other published medium-to-long term studies reported overall good outcomes, with no differences after small fragment fixation. The unfixated smaller posterior malleolus fragment demonstrated overall satisfactory clinical and radiographical outcomes at 10-year follow-up and may be considered a valid treatment strategy

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

Talar body fractures are high energy intraarticular injuries that are best management by anatomical reduction and secure fixation to improve outcomes. The talus is relatively inaccessible surgically and requires extensive soft tissue dissection and/or osteotomies to gain adequate open visualisation. There are a small number of case reports on arthroscopic assisted fixation in the literature. This case series reports on the technique and early outcomes of six patients all of whom presented with significant intraarticular displacement and who were managed entirely arthroscopically. The fractures were of the main body of the talus involving the ankle and subtalar joints and all had preoperative CT scans. All six patients underwent posterior ankle and subtalar arthroscopy with cannulated screws used to stabilise the fractures after reduction. Visualisation of the fracture reduction was excellent. After 10 days in a backslab, the patients were protected in a boot and encouraged to actively move their ankles. Weight bearing was permitted once union appeared complete. There were no early complications of infection, avascular necrosis or VTE. There was one patient that had a non-clinically significant migration of a screw. Two patients were lost to follow up early due to being visitors. The mean length of follow up was 12 months in the remainder. The remaining four patients all returned to their preoperative level of activity. All had demonstrable subtalar stiffness. There was no early post-traumatic arthritis. This series represents the largest so far published. The main flaw in this report is the lack of long term follow up. While this report cannot state superiority over open techniques it is a safe, effective and acceptable technique that has significant conceptual benefits

Introduction. Anatomic reduction of talar body fractures is critical in restoring congruency to the talocrural joint. Previous studies have indicated a maximum of 25% talar body exposure without malleolar osteotomy. The aim of this study was to investigate the percentage talar body exposure when using the lateral transligamentous approach. Methods. The lateral transligamentous approach to the talus was undertaken in 10 fresh frozen cadaveric specimens by surgeons inexperienced in the approach, following demonstration of the technique. An incision was made on the anterolateral aspect of the ankle augmented by the removal of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) from their fibular insertions. A bone lever was then placed behind the lateral aspect of the talus and levered forward with the foot in equinus and inversion. The talus was disarticulated and high resolution images were taken of the talar dome surface. The images were overlain with a reproducible nine-grid division. Accessibility to each zone within the grid with a perpendicular surgical blade was documented. ImageJ software was used to calculate the surface area exposed with each approach. Results. The mean percentage area of talar dome available through the transligamentous approach was 77.3 % (95% confidence interval 73.3, 81.3). In all specimens the complete lateral talar process was accessible, along with the lateral and dorsomedial aspect of the talar neck. This approach gives complete access to Zones 1,2, 3,5 & 6 with partial access to Zones 4,8 & 9. Conclusion. The lateral transligamentous approach to the talus provides significantly greater access to the talar dome as compared to standard approaches. The residual surface area that is inaccessible with this approach is predominantly within Zone 4 and Zone 7, the posteromedial corner

Background. Current literature of definition, classification and outcomes of fractures of talar body remains controversial. Our primary purpose is to present an unusual combination of fractures of talar body with pantalar involvement / dislocation / extension as a basis for modification of Müller AO / OTA Classification. Methods. We include four consecutive patients, who sustained talar body fractures with pantalar subluxation/dislocation /extension. These unusual injury patterns lead us to reconsider Müller AO / OTA Classification in the light of another widely used talar fracture classification, Hawkins Classification of fractures of neck of talus and subsequent modification by Canale and Kelly. Results. Müller AO / OTA Classification comprises CI – Ankle joint involvement, C2 – Subtalar joint involvement, C3 – Ankle and subtalar joint involvement. We propose Modification of Müller AO / OTA. Classification. C1 – Absolutely undisplaced fracture; C2 – Ankle and Subtalar joint involvement: subluxation; C3 – Ankle and subtalar joint involvement: subluxation with comminution; C4 – Ankle, subtalar and talonavicular joint involvement. Conclusions. Our modification redefines Müller AO / OTA Classification, extends and fills the void in the classification by inclusion of C4, draws attention to stability of talonavicular joint and reflects increasing severity of injury in fractures of talar body

Background: Fractures of the talus represent serious injuries of the foot skeleton. The most significant complications include osteonecrosis and posttraumatic mal-alignment with subsequent arthritis. The aim of our study was to compare treatment and outcome of fractures of the talus between children and adolescents. Methods: From 1990 to 2005 24 patients (18 male, 6 female) presented with 25 fractures of the talus. The medical records were reviewed retrospectively. At follow-up the functional outcome was measured using the Foot-Function-Index. Results: 9 patients were 12 years of age or younger, 15 patients presenting 16 talar fractures were older than 12 years. While the majority of fractures of the talus in children younger than 12 years of age were classified as Marti-Weber Type I and II fractures, more than two thirds of the fractures in patients older than 12 years were Marti-Weber Type III and IV fractures. Two thirds of the patients younger than 12 years were treated non-operatively while non-operative treatment was possible in only 3 talar fractures in adolescents. No necrosis at follow-up (mean period: 3.2 years, range 7 months to 8.4 years following end of treatment) was detected in children (< 12 a), while 5 patients older than 12 years developed persisting necrosis. Conclusion: Even tough there is no apparent difference in the cause of the trauma leading to fractures of the talus adolescents present with more severe fractures of the talus compared to children younger than 12 years of age. Additionally we did not observe persistent osteonecrosis in patients less than 12 years old and the outcome is favorable in the majority of the cases irrespective of the mode of treatment

Introduction and purpose: Talar fractures are infrequent but are an important cause of morbidity. Materials and methods: This is a retrospective study of talar fractures treated in our Hospital between 1997 and 2006 (10 years). Results: We collected 44 fractures in 42 patients (37 men and 5 women), with a mean age of 33 years (range: 8–67 years). The cause of the fractures in 40 cases was high-energy trauma and in 4 cases low-energy trauma. The most frequent causes were traffic accidents (29) and falls (8). Mean hospital stay was 14 days. We found 22 neck fractures, which were classified accoding to Hawkins’ scale (10 type I, 9 type II and 3 type III), 19 fractures of the body (7 due to crushing, 5 coronal, 4 osteochondral, 2 sagittal and 1 of the lateral process), and 3 combined neck and body fractures. We did not see any head fractures. We found 5 fracture-dislocations, 2 subtalar fractures associated to a neck fracture and 2 complete dislocations. Nine of the 44 fractures were open (1 grade I, 5 grade II, 2 grade IIIA, 1 grade IIIB). Only 9 of the 42 patients did not have associated lesions. Of those that did have associated lesions, 52% had adjacent lesions and 57% had distant lesions. Twenty-six fractures underwent surgery, 20 with cannulated screws (6 anterograde and 14 retrograde) and 6 with Kirschner wires. Follow-up was carried out in 24 of these patients and the complications seen were 2 osteonecrosis, 5 skin necroses, 12 cases of posttraumatic arthritis, 3 infections, 2 malunions, and 8 cases of intolerance of osteosynthesis material. Hawkins’ sign was assessed in the neck fractures, and osteopenia was found in 6 fractures, none of which developed osteonecrosis. In the 3 patients who did not have osteopenia, 2 ischemic necroses were seen. Conclusions: The rate of osteonecrosis was 13% in the patients followed up, less than that seen in published series. A positive Hawkins’s sign is reassuring as none of the patients with subchondral osteopenia at 6–8 weeks subsequently developed osteonecrosis

Background. Talar neck fractures occur infrequently and are associated with high complication rates. Anatomical restoration of articular congruity is important. Adequate exposure and stable internal fixation of these fractures are challenging. Aims. We investigate the use of an anterior extensile approach for exposure of these fractures and their fixation by screws introduced through the talo-navicular articulation. We also compare the quality and quantity of exposure of the talar neck obtained by this approach with the commonly described combined medial/lateral approaches. Materials and Methods. An anterior approach to the talus between the tibialis anterior and the extensor hallucis longus tendons protecting both the superficial and deep peroneal nerves was performed on 5 fresh frozen cadaveric ankles . The surface area of talar neck accessible was measured using an Immersion Digital Microscibe and analysed with Rhinoceros 3D graphics package. Standard antero-medial and antero –lateral approaches were also carried out on the same ankles, and similar measurements taken. Seven patients with talar neck fractures (4 Hawkins Type II and 3 Hawkins Type III) who underwent operative fixation using this approach with parallel cannulated screws through the talo-navicular joint were followed and the clinical radiological outcomes were recorded. Results. 3D mapping demonstrated that talar surface area visible by the anterior approach (mean 1200sqmm) is consistently superior to that visible by either the medial or lateral approaches in isolation or in combination (mean medial 350sqmm, mean lateral 600sqmm). Medial malleolar osteotomy does not offer any additional visualisation of the talar neck. 3D reconstruction of the area visualised by the three approaches confirms that the anterior approach provides superior access to the entirety of the talar neck. 5 male and 2 female patients (mean age -) were reviewed at a mean follow up period of 6 months. All had anatomical articular restoration, and no wound problems. None developed non or AVN. There were no symptoms referable to the talo-navicular joints which showed no evidence of any secondary changes on the radiographs. Discussion. The anterior extensile approach offers superior visualisation of the talar neck in comparison to other approaches for anatomical articular restoration. Surgical morbidity with this approach is low, and introduction of screws through the talo-navicular joint allows stable fixation of talar neck fractures along the axis of the bone. We argue that this approach is safe, adequate and has the potential to cause least vascular disruption

Aims: Consideration of gravity of talar neck fractures and evaluation of their treatment results. Methods: From 1992 to 2001 were admitted to our department 26 patients, suffering from talar neck fractures. We were able to reexam 22 patients (17 males and 5 females), with mean age 34,14y. (16 to 64y.). Fourteen pt. (63,6%) were car accident victims. In the rest of them fracture occurred after fall from height more than 3m. There were 8 (36.3%) multi-injured patients. Preoperative diagnostic approach included simple x-rays and CT scan and Hawkins classiþcation was used. All patients underwent surgical treatment. Operative technique included open reduction and internal þxation using screws and/or K-Ws. Postoperatively patients were evaluated with radiological and clinical criteria according to Iowa Ankle Evaluation score. Results: Mean follow up was 58 months (from 12 months to 9 years). Results were excellent in 10 (45,4%), good in 6 (27.2%), fair in 4 (18.1%) and poor in 2 (11%) patients. Two cases developed avascular necrosis (1 type D and 1 type C) followed by body collapse and treated with ankle arthrodesis. Furthermore 1 patient underwent ankle and 6 patients subtalar arthrodesis because of arthritis caused from concomitant fractures. Conclusions: Treatment of talar neck fractures is a challenge because of high rate of complications, because of talusñ shape and vascular anatomy. Anatomic reduction and rigid internal þxation, in combination with immobilization and no weight bearing until restoration of talusñ architecture is achieved, are essential requirements for good result

The aim of this study was to evaluate the early results and complications of internal fixation for displaced fractures of the talar neck. A retrospective review was undertaken of displaced talar neck fractures. 35 patients had open reduction and lag screw fixation during a 16-year period. All patients were followed with serial radiographs for at least three years. There were 25 males and 10 females with a mean age of 31 years (range 15–61 years). The most common mechanism of injury was fall from height (n=13) and motor vehicle accidents (n=l1). There was one bilateral fracture. Ipsilateral ankle fractures occurred in 5 patients (14%) and 8 patients (23%) had multiple injuries. There were 31 Hawkins’ type II fractures and 5 Hawkins’ type III fractures. 25 patients (71%) had no complications as a result of their injuries or surgery. All fractures united within 6 months. There was one deep infection (3%) in a IIIB open fracture that required early amputation. 8 patients developed avascular necrosis: 6 Hawkins’ type II fractures (19%) and 2 Hawkins’ type III fractures (40%). Avascular necrosis was more common if surgery was delayed beyond 24 hours but this may reflect the severity of injury rather than the timing of surgery. The outcome following avascular necrosis was poor in general and 5 patients (63%) required hindfoot fusion. Talar neck fractures are rare. This is the first study from the UK to evaluate this injury and it is the first to look specifically at one method of operative treatment. In general, the early results were good with only 1 deep infection (3%) and all fractures united following lag screw fixation. Avascular necrosis remains the most common complication but, compared with other studies, we report low rates of this problem. Good results can be obtained following lag screw fixation of displaced talar neck fractures. The complication rate is low but avascular necrosis remains a serious problem

The April 2014 Trauma Roundup. 360 . looks at: is it safe to primarily close dog bite wounds?; conservative transfusion evidence based in hip fracture surgery; tibial nonunion is devastating to quality of life; sexual dysfunction after traumatic pelvic fracture; hemiarthroplasty versus fixation in displaced femoral neck fractures; silver VAC dressings “Gold Standard” in massive wounds; dual plating for talar neck fracture; syndesmosis and fibular length easiest errors in ankle fracture surgery; and dual mobility: stable as a rock in fracture

Talar neck fractures are associated with high complication rates with significant associated morbidity. Adequate exposure and stable internal fixation remains challenging. We investigated the anterior extensile approach for exposure of these fractures and their fixation by screws introduced through the talo-navicular articulation. We also compared the quality and quantity of exposure of the talar neck obtained by this approach, with the classically described medial/lateral approaches. An anterior approach to the talus between the tibialis anterior and the extensor hallucis tendons protecting both the superficial and deep peroneal nerves was performed on 5 fresh frozen cadaveric ankles . The surface area of talar neck accessible was measured using an Immersion Digital Microscribe and analysed with Rhinoceros 3D graphics package. Standard antero-medial and antero –lateral approaches were also carried out on the same ankles, and similar measurements taken. Seven talar neck fractures underwent operative fixation using the anterior approach with parallel cannulated screws inserted through the talo-navicular joint. 3D mapping demonstrated that the talar surface area visible by the anterior approach (mean 1200sqmm) is consistently superior to that visible by either the medial or lateral approaches in isolation or in combination. Medial malleolar osteotomy does not offer any additional visualisation of the talar neck. 3D reconstruction of the area visualised by the three approaches confirms that the anterior approach provides superior access to the entirety of the talar neck. 5 male and 2 female patients were reviewed. All had anatomical articular restoration, and no wound problems. None developed non union or AVN. The anterior extensile approach offers superior visualisation of the talar neck in comparison to other approaches for anatomical articular restoration. We argue that this approach is safe, adequate and causes less vascular disruption

Introduction: We present the results of the Ankle Evolution System (AES) total ankle replacements with a minimum follow up of four years. Methods: Forty-five consecutive patients who had AES ankle replacement were included in the study. The mean age at operation was 64.6 (50–77). Pain and function were assessed using the AOFAS score. Patients had standardised AP and lateral weight bearing radiographs and were assessed for loosening and alignment. Patients’ satisfaction and complications were recorded. The survival of the implant was constructed using the Kaplan-Meier survival curve. Results: The mean follow up for our patients who were alive and available for follow up at the final clinical review (40 patients) was 57.8 months (48–80). A total of 2 patients were revised (One patient sustained talar fracture and was converted to arthrodesis at three years postoperatively. The second patient had revision of the tibial component because of aseptic loosening at 4 years postoperatively). The mean total AOFAS score was 88.1 (53–100). For pain the mean score was 35.8 (20–40). Nine patients showed osteolysis only 2 were considered as significant. Those patients had minimal symptoms that were not progressing and further surgery was not justified. Ten patients presented with edge loading of which nine had corrective surgery. Our cohort showed high patients’ satisfaction. Our cumulative survival rate at 6 years was 94.7% with revision or decision to revise as the endpoint. Conclusion: The medium term results of the mobile AES total ankle replacement in terms of survivorship, functional outcome and patients’ satisfaction are satisfactory but we have our concerns about the high rate of osteolysis. The long-term benefit of this procedure has yet to be determined

To analyze the results in proportion to the type of talar fracture. Eighteeen talar fractures(8 of the body and 20 of the neck)in 28 patients(24 men and 4 women, between 22 and 60 years, of average age 42 years) were treated in our department in the period 1981–2007. 24 fractures were closed and 4 were open (2 B and 2 C1 grade). The Hawkins classification for the fractures of the neck is: 10 type I, 6 type II, 4 type III. The fractures of the body were: 1 type A, 4 type B, 3 type E. The most common mechanism of injury was fall from a height in 16 cases and car accidents in 12 cases. 18 patients had associated injuries. The fractures managed within 6 hours. Time of follow up ranged between 2 and 9 years. All type I fractures of neck were treated conservatively with excellent results (Hawkins score). All type II were operated and healed with results ranging from very good ones to medium ones. From type III, one had a very good result, one medium and 2 manifested osteonecrosis. From the fractures of the body all (except three: 1 type A, 1 type B and 1 type E) manifested osteonecrosis. The time of union ranged between 2,5 and 4,5 months. There was no deep infection and 9 complications were observed. Our results agree with those of international bibliography for these rare fractures. The fractures of the body and the type III of the neck have the worst prognosis

Tarsal fractures are rare in children. Clinical and radiographic evaluation of these injuries can be difficult. We present a retrospective study documenting all tarsal fractures presenting to an inner-city children’s hospital in the UK over a fifteen year period. Of 70 case notes retrieved from the hospital database, 7 patients were excluded due to inadequate data. This resulted in 69 tarsal injuries in 63 patients being included. Mean age at presentation was 9.3 years (2.5 – 13.9). 80% were male. 72% were calcaneal fractures, 12% cuboid, 9% navicular, 4% talus and 2% medial cuneiform. The main method of diagnosis was plain x-rays. Cause of injury was predominantly fall from height, crush or road traffic accident. 25% had another associated lower extremity injury. Three patients had bilateral tarsal injuries. Only 3% had upper limb injuries and there were no injuries with spinal involvement. Calcaneal fractures were treated with a short leg cast for a mean time of 4.1 weeks (2–6). Mean time to recovery was 5.7 weeks (2–20). Mean time to discharge from clinic was 7 weeks (2–40). There were two patients with open fractures requiring surgical debridement. One patient with a talar fracture had percutaneous fixation. Only one patient re-presented with pain following discharge. X-rays showed healing avascular necrosis of the proximal talus. Tarsal fractures are rare, usually benign and most require simple immobilisation for only a short period of time. Surgical intervention is only occasionally required in complex injuries. Complications and long term problems are rare, even following open injuries

Purpose: To evaluate the appropriateness of posterior blade plate ankle arthrodesis as a salvage procedure, in a complex subgroup of ankle trauma patients. Methods: We retrospectively identified all patients who underwent an ankle arthrodesis from our prospectively collected trauma database at Vancouver General hospital from 1997 to 2005. We then extracted those who had blade plate arthrodesis via the posterior approach for previous failed fracture fixation or failed previous fusion. Demographics, pre arthrodesis diagnosis, previous surgeries, deformity and complications were recorded. Clinical examination was based on outpatient evaluation and physical evaluation. This was supplemented with radiological follow up to confirm union and outcome scoring using the AOFAS and SF36 systems. Results: Sixteen patients were identified from the trauma database who had undergone posterior blade plate ankle arthrodesis. Of these thirteen were available for follow up. There average age was 47 years (range 23–63 years). The male to female ratio was 3:1. Three cases were for failed previous ankle fusion by other means. Of the remaining ten patients with post traumatic osteoarthritis, seven had previous pilon fractures, two talar fractures and one fracture dislocated ankle. All cases went onto bony union. Patient satisfaction was good although functional outcome scoring was not normal. Conclusion: We have found this procedure to have several excellent benefits. It allows the surgeon to operate through virgin skin, reducing potential wound complications, and achieve good soft tissue coverage. The blade plate allows reconstitution of a normal plantar grade ankle and distal tibial orientation, when secured appropriately to bone. Excellent compression and union can be achieved with the AO compression device, but it’s important to have a second screw in the talus to prevent blade pull out. The procedure has good satisfaction among patients following previous failed surgery, as a salvage procedure

From October 1999 to April 2003, 123 patients (127 ankles) underwent an Agility total ankle replacement. Prospective data were collected preoperatively, at 6 and 12 months after surgery, and thereafter annually, and included the AOFAS Ankle and Hindfoot Scale (AHS), Musculoskeletal Functional Assessment Injury and Arthritis Survey (MFA), Visual Analogue Pain Scale, patient satisfaction and standardised radiographs. Fifty-six percent of the operations were performed for post-traumatic degenerative joint disease, 41% for primary degenerative joint disease, 1% for rheumatoid arthritis and 2% for avascular necrosis. At least one previous surgical procedure had been performed on 62% of ankles. In 6% there were intra/perioperative complications, including seven wound problems (one major, six minor), five lateral fractures, one medial malleolus fracture, one bone stock deficiency, one tibial nerve injury, one ankle in varus and one flap necrosis. Late complications included eight syndesmosis nonunions that needed bone grafting, one infection that led to a fusion, one unrelated talar fracture that led to a fusion, and one component subsidence that was revised. There were two patients with progressive varus and two with progressive valgus deformities. One patient underwent a below-knee amputation for chronic infection. Most of the perioperative complications occurred in the first 40 patients. The preoperative AHS of 43 (4 to 70) increased six months postoperatively to 75.45 and to 85 at two years. Patient satisfaction preoperatively was 0.92 out of 5 and 4.2 at two years. Baseline MFA values indicative of severe dysfunction (9.26) showed marked improvement in all parameters at two-year follow-up (21.83). The Agility ankle replacement procedure is technically demanding and there are pitfalls and complications. The early results are promising, but follow-up has not been long enough to permit an objective opinion

Os calcis fracture patterns in ten children (mean age 12. 8) with eleven fractures were classified using plain films and CT scans and found to be similar to those in adults. All except two of the fractures (which were not significantly displaced) were treated with open reduction and internal fixation. In all cases it was possible to achieve anatomic reduction and rigid internal fixation. Eight patients had ‘excellent’ long-term clinical results. One patient with a court case pending scored ‘good’, and one patient with an ipsilateral talar neck fracture scored ‘fair’. This patient had mildly limited ankle movement; all others had full ankle movement. Six had full subtalar movement, in 2 it was mildly limited and in three it was moderately limited (50–80%). There was no evidence of abnormality of the physes on follow up x-rays. We conclude that operative treatment of these fractures yields optimal results

A research programme has been directed at the mechanism by which car occupants sustain ankle and hind-foot injuries. The severe injuries that are most associated with long term disability and high socio-economic cost have been investigated. Although seat belts and air bags have had a beneficial effect on injuries to most body regions including pelvic, femur and knee injuries, no protective effect has been demonstrated for below knee injuries. Only by understanding the mechanism of injuries to the leg below the knee will it be possible to design improved protection in the future. Twenty three post mortem human surrogate (PMHS) limbs were impacted using a test set up that was developed to simulate the loading conditions seen in a frontal collision in 3 different positions – A, B & C. The impactor head (5cm x 10cm wide), was instrumented with an accelerometer and linear potentiometer. The impacting force was generated using a bungee-powered sled mounted on steel bearings. Three PMHS legs were tested In Position A (impactor head centred in line with the tibial axis), 9 PMHS legs were tested in Position B (impactor head centred on the anterior tibial margin) and 11 PMHS legs were tested in Position C (impactor head centred 2.5cm anterior to the anterior tibial margin). Active dorsiflexion was simulated through the Achilles tendon and prior to the application of Achilles tension a tibial pre-load (500 to1500N) was applied via a ‘jacking-plate’ applied to the proximal end of the tibia. During impact testing, bone failure (fractures) occurred at impact loads of 5.7+/−1.9 kN (resultant tibial failure load 6.4+/−1.9 kN) and the following injuries were generated: 9 intra-articular calcaneal fractures; 1 talar neck and 2 talar body fractures; 3 intra-articular distal tibial (pilon) fractures; 2 malleolar fractures; 3 soft tissue injuries and in 3 cases there was no detectable injury. The impact test conditions were replicated with a Hybrid III leg in a first attempt at developing injury risk functions for the dummy. This study has demonstrated the importance of preload through muscle tension in addition to the intrinsic properties of PMHS specimens in the generation of severe ankle and hindfoot injury