Aims. The aim of this study was to compare the longer-term outcomes of operatively and nonoperatively managed patients treated with a removable brace (fixed-angle removable orthosis) or a plaster cast immobilization for an acute ankle fracture. Methods. This is a secondary analysis of a multicentre randomized controlled trial comparing adults with an acute ankle fracture, initially managed either by operative or nonoperative care. Patients were randomly allocated to receive either a cast immobilization or a fixed-angle removable orthosis (removable brace). Data were collected on baseline characteristics, ankle function, quality of life, and complications. The Olerud-Molander Ankle Score (OMAS) was the primary outcome which was used to measure the participant’s ankle function. The primary endpoint was at 16 weeks, with longer-term follow-up at 24 weeks and two years. Results. Overall, 436 patients (65%) completed the final two-year follow-up. The mean difference in OMAS at two years was -0.3 points favouring the plaster cast (95% confidence interval -3.9 to 3.4), indicating no statistically significant difference between the interventions. There was no evidence of differences in patient quality of life (measured using the EuroQol five-dimension five-level questionnaire) or Disability Rating Index. Conclusion. This study demonstrated that patients treated with a removable brace had similar outcomes to those treated with a plaster cast in the first two years after injury. A removable brace is an effective alternative to traditional immobilization in a plaster cast for patients with an ankle fracture. Cite this article: Bone Joint J 2023;105-B(4):382–388

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

Ankle fractures represent the third most common fragility fracture seen in elderly patients following hip and distal radius fractures. Non-operative management of these see complication rates as high as 70%. Open reduction and internal fixation (ORIF) has complication rates of up to 40%. With either option, patients tend to be managed with a non-weight bearing period of six weeks or longer. An alternative is the use of a tibiotalocalcaneal (TTC) nail. This provides a percutaneous treatment that enables the patient to mobilise immediately. This case-series explores the efficacy of this device in a broad population, including the highly comorbid and cognitively impaired. We reviewed patients treated with TTC nail for acute ankle fractures between 2019 and 2022. Baseline and surgical data were collected. Clinical records were reviewed to record any post-operative complication, and post-operative mobility status and domicile. 24 patients had their ankle fracture managed with TTC nailing. No intra-operative complications were noted. There were six (27%) post-operative complications; four patients had loosening of a distal locking screw, one significant wound infection necessitating exchange of nail, and one pressure area from an underlying displaced fracture fragment. All except three patients returned to their previous domicile. Just over two thirds of patients returned to their baseline level of mobility. This case-series is one of the largest and is also one of the first to include cognitively impaired patients. Our results are consistent with other case-series with a favourable complication rate when compared with ORIF in similar patient groups. The use of a TTC nail in the context of acute, geriatric ankle trauma is a simple and effective treatment modality. This series shows acceptable complication rates and the majority of patients are able to return to their baseline level of mobility and domicile

Diabetes is a poor prognostic indicator after an acute ankle fracture. Many surgeons avoid essential surgery due to their concerns regarding complications. We performed a retrospective analysis of complication rates for acute ankle fractures in diabetics with a control non-diabetic patient treated by all surgeons in our unit and assessed factors for success including long-segment fixation methodologies. Patient records were cross-referenced with departmental databases and a retrospective review of all ankle fractures managed in our department was conducted from 2014. All patients subjected to a retrospective review of their notes and assessment of their follow up for at least 6 months. Radiographs were assessed of the ankle before and at completion of treatment were reviewed independently (RA and FR). We identified all patients with a diabetic ankle fracture their HB1Ac (for diabetic control) and systematic co-morbidities. Fractures were classified into unimalleolar, bi malleolar and trimalleolar and surgery grouped into standard or long-segment-rigid fixation. Statistical analysis was conducted using absolute/relative risk (RR); numbers needed to treat (NNT) were calculated. We compared a control-group, a diabetic group managed conservatively, and undergoing surgery; comparing the concept of rigid fixation. Further sub-analysis conducted to assess differences between diabetic neuropathy, retinopathy and nephropathy. Ethics approval was granted as per our institutional policy by our governance lead. We identified 64 patients with a diabetic ankle fractures, their fracture pattern and a control group. Thirty-one had conservative treatment; 33 had operative fixation of which 13 had rigid fixation. Compared to the control (n=32) both diabetic groups had a higher risk of possible complication. The relative risk was between 3.1–3.4 (P<0.002) and linked to systematic complications of diabetes e.g. neuropathy 5.9 (P<0.003); HBA1c 4.6 P<0.004); and neuropathy and retinopathy 6.2 P<0.0003). We observed RR is reduced for a complication occurring following surgery with prolonged immobilization (0.86) and rigid fixation (0.65) and NNT required to see a benefit from rigid fixation was 7. The overall RR for a complication was similar between conservative and surgical management (4.6 vs.5.1). We agree diabetics have a higher risk for complications than non-diabetics, however the risk is not as great as previously reported. There is little difference in surgical or conservative treatment but strong evidence indicating rigid long-segment-fixation with prolonged-immobilization could improve the risk benefit ratio when compared to non- operative management alone but further evaluation is required

Closed ankle fractures have been reported to account for 10% off all fractures presenting to the Emergency Department. Many of these injuries require acute surgical management either via direct admission or through defined outpatient surgical pathways. While both methods have been shown to be safe, few studies have examined the cost effectiveness of each clinical scenario. The purpose of this study is to compare cost and resource utilization associated with inpatient and outpatient ankle fracture surgery at a Canadian academic institution. This is a retrospective chart review of patients who underwent acute ankle fracture surgery at London Health Sciences Centre between 2016 and 2018. Thirty patients who underwent inpatient ankle surgery for closed, isolated ankle fractures at University Hospital were compared to 30 consecutive patients who underwent outpatient ankle surgery for similar fractures at Victoria hospital. Data pertaining to age at time of surgery, sex, BMI, fracture type, operating/recovery room time, and length of hospital stay were collected. All emergency room visits, readmissions and complications within 30 days of surgery were also recorded. Inpatient and outpatient cohorts were similar with respect to average age (48 vs. 44, P=0.326) and body mass index (29.8 vs. 29.1, P=0.741). There was a greater proportion of patients with an American Society of Anesthesia (ASA) Classification of 3 or greater in the inpatient surgery group (48% vs. 23%). The inpatient group spent an average of 1.2 days in hospital while waiting for surgery and a average of 72 hours in hospital for their entire surgical encounter. The outpatient group spent an average of eight days (at home) waiting for surgery while spending an average of 7.4 hours in hospital during their entire surgical encounter. Outpatient ankle fracture surgery was associated with a cost savings of 35.9% in comparison to inpatient ankle fracture surgery (P < 0 .001). There were no significant differences in the rates of emergency room visits, readmissions, or complications between cohorts. Preliminary findings suggest that outpatient ankle fracture surgery is appropriate for most patients, requires less hospital resources and is associated with similar rates of readmission and complications as inpatient surgery. An established outpatient surgical pathway may offer significant cost savings in the treatment of the common closed ankle fracture that requires surgical intervention

Introduction. Standard teaching of dislocated ankles was always reduce then x-ray. However the 2016 BOAST guidelines stated “Reduction and splinting should be performed urgently for clinically deformed ankles. Radiographs should be obtained before reduction unless this will cause an unacceptable delay”. We aimed to audit our practice against the BOAST guidelines and look at time from attendance to reduction. Methods. We retrospectively reviewed all case notes of patients admitted via A&E at the Northern General Hospital with a fractured ankle between August 2016 and January 2017. Time of arrival, time to x-ray and time to reduction were recorded in a database for analysis. Results. 65 patients with acute ankle fractured dislocations were identified from 140 acute fractured ankle referrals to the orthopaedic on-call team. 55 of these had a pre-reduction x-ray. Time from arrival to a radiograph of a reduced ankle in cast was 3hrs 59 minutes for those who had a pre-reduction radiograph compared with 1hr 3 minutes for those who didn't have a pre-reduction radiograph. 12.5% of those with no pre-reduction radiograph required re-manipulation compared with 31% of those who did have a pre-reduction radiograph. Conclusion. Having a pre-reduction x-ray significantly increases the time until there is radiological evidence of a reduced ankle. There was an associated higher risk of requiring a further manipulation in those who had a pre-reduction radiograph. A larger review is currently being undertaken to better understand the possible reasons for this

Diabetes is a poor prognostic indicator after an ankle fracture. Many surgeons avoid operating due to concerns regarding complications. We performed a retrospective analysis of complication rates for acute ankle fractures in diabetics with a control non-diabetic patient treated by all surgeons in our unit and assessed factors for success including long-segment fixation. Patient records were cross-referenced with departmental databases and a review of all ankle fractures managed in our department was conducted from 2012. All patients subjected to a retrospective-review of their follow-up for at least 6-months. Radiographs were assessed of the ankle before and at completion of treatment being reviewed independently (RA & FR). We identified the HB1Ac (diabetic-control) and systematic co-morbidities. Fractures were classified into unimalleolar, bi malleolar and trimalleolar and surgery grouped into standard or long-segment-rigid fixation. Statistical analysis was conducted using absolute/relative risk (RR); numbers needed to treat (NNT) were calculated. We compared a control-group, a diabetic group managed conservatively, and undergoing surgery; comparing the concept of rigid fixation and prolonged imobilisation in isolation or combined. Further sub-analysis conducted assessing diabetic neuropathy, retinopathy and nephropathy. Ethics approval was granted as per our institutional policy by our governance lead. We identified 154 diabetic ankle fractures, seventy-six had conservative-treatment; 78 had operative fixation of which 23 had rigid-long-segment-fixation. The diabetic-groups had a higher risk-relative-risk of complication − 3.2 (P< 0.03) being linked to systematic complications of diabetes e.g. neuropathy 5.8 (P< 0.003); HBA1c 4.6 P< 0.004); and neuropathy or retinopathy 6.2 (P< 0.0003). Relative-risk reduction of complications occurred following surgery with prolonged immobilization (0.86) and rigid-fixation (0.65). The Number-Needed-to-Treat required to see a benefit from rigid fixation was 7. Diabetics have a higher risk for complications, however the risk is not as great as previously reported. We provide evidence of rigid-long-segment-fixation with prolonged-immobilization improving-outcomes

Adverse weather conditions during the winter months put increased pressure on orthopaedic trauma departments across the country. The increased incidence of injuries has resulted in a strain on resources at a local level and a situation can arise whereby cases need to be prioritised according to clinical need and fitness of the patient. Ankle fractures, frequently caused by slipping in adverse weather conditions, tend to be an injury where a high proportion of patients are young and active and can therefore cope better physiologically waiting several days for their operation. It is well documented that there is a window of opportunity when operating on ankle fractures, during which the swelling will permit fixation. We aimed to establish whether a link exists between delay to surgery for ankle fractures, the length of post-op hospital stay and the rate of complications. We included all patients who underwent surgical fixation of an ankle fracture over a three month period between 1.1.10 and 31.01.11. Data was obtained through theatre records, discharge and clinic letters and from the local PACS X-ray system. Basic patient data, admission, theatre and discharge dates were collected along with details regarding mechanism of injury, type of fracture, fixation and documented complications. Patients were subdivided into two groups: those who underwent surgery within 48 hours of injury and those who waited longer than 48 hours. Many of the patients in the delayed surgery group remained inpatient until after their surgery whilst those more capable of mobilising with crutches were allowed home to elevate. 64 patients underwent fixation of an acute ankle fracture during the three month study period. 28 patients (44%) had a documented fall on ice or snow. 29 patients were operated upon within 48 hours. 35 patients surgery was delayed by a mean of 9 days (3-28). The mean length of post op hospital stay for the early surgery group was 3.00 days. In the delayed surgery group the mean length of stay was 4.28 days (p=0147). There were 4 complications in the early group (14%) compared with 7 in the delayed group (20%). Delaying surgery for ankle fractures more than 48 hours suggests a trend towards an increased length of post-operative hospital stay and a slightly increased rate of complications but not to significant levels. A larger sample size may have provided a significant difference. Given this trend, we recommend early fixation of ankle fractures wherever possible providing soft tissue swelling allows tension free wound closure

The October 2012 Trauma Roundup³⁶⁰ looks at: which patients die from pelvic ring fractures; monolateral distraction osteogenesis; surgical management of pelvic and peroneal blast injuries; weekend warriors at risk of going AWOL; early experience with the locking attachment plate; and fibula nailing - an alternate, and viable technique.