Decreased ankle dorsiflexion is common after injury and may result in patient complaints of stiffness and subsequent injury. The weight-bearing lunge test (WBLT) is a simple clinical measure of dorsiflexion. Previous study has defined a 2.0cm side-to-side discrepancy in WBLT as likely significant. With review of current literature, ankle stiffness is a concept largely undefined; we aim to relate patient complaints of stiffness to WBLT. This was a population-based inception cohort with longitudinal follow-up. Patients between ages 18–65 receiving surgical fixation for ankle fracture were screened. Pilon/plafond fractures, bilateral injuries, or polytrauma were excluded. At 6-weeks, 6-months, and 1-year WBLT was measured along with non-weight-bearing goniometry; and an Olerud-Molander ankle score completed. 155 patients were recruited (90 female, 65 male; mean age 42, range 20–67). 47% of injuries were unimalleolar, 17% bimalleolar, and 36% trimalleolar; 35% received syndesmotic fixation. 89% of patients reported feeling stiff at 6-weeks, 82% at 6-months, and 74% at 1-year. 98% of patients had ≥2.0cm discrepancy of WBLT at 6-weeks, 78% at 6-months, and 72% at 1-year. Different thresholds of WBLT (larger discrepancy or absolute negative measurement) had worse correlation with patient reported stiffness. Our population had high incidence of stiffness at 1-year. The proportion of patients complaining of stiffness after ankle fracture was similar to that measured with ≥2.0cm discrepancy of WBLT. This is the first study that we are aware of that relates the WBLT and the previously reported threshold of 2.0cm to stiffness. This measurement may give clinicians a better objective idea regarding patient perception of a “stiff” ankle. Reducing side to side discrepancy in range of motion should be considered in rehabilitation rather than total range of motion

This prospective observational study was designed to report the soft tissue complications after fixation of tibial plafond fractures in an effort to challenge the current recommendation that a seven centimeter skin bridge represents the minimum safe distance between surgical incisions. Our hypothesis was that many of the skin bridges would be less than seven centimeters and that this would not result in an increased incidence of wound complications. All injuries received surgical treatment using a minimum of two surgical approaches for the tibial plafond and the associated fibula fracture (if applicable). Forty-two adult patients with forty-six tibial plafond fractures were enrolled in the study between July 1, 2004 and Dec 30, 2005. There were 1 A1, 3 B1, 2 B3, 6 C1, 6 C2 and 28 C3 fractures. Forty-four plafond fractures had an associated fibular fracture. There were thirty-six closed and ten open fractures. High energy injuries were managed using a two staged approach consisting of fibular ORIF through a posterolateral approach combined with spanning external fixation, followed by tibial ORIF when soft tissue swelling subsided (forty-four fractures). The surgical approaches used, the length of the incisions, the distance between the incisions (size of the skin bridge), and the overlap between the incisions was recorded. The surgical wounds were followed until healing and for a minimum of three months. Two surgical approaches were used in thirty-two fractures and three approaches were used in fourteen. These one hundred and six surgical incisions produced sixty skin bridges. The approaches used included pos-terolateral (forty-four), anterolateral (thirty-nine), medial (eleven), anteromedial (eight), and posteromedial (four). The mean skin bridge size was 5.9 cm. Only 15% of the skin bridges were > 7 cm, while 70% were 5–7 cm, and 15% were < 5 cm. The mean overlap between incisions in the study was 7.9 cm. One hundred two incisions healed uneventfully. Healing of two anterolateral incisions was complicated by eschars that resolved with local wound care. One posterolateral fibular incision failed to heal until the fibular plate was removed. One patient required subsequent surgical procedures for infection. Despite a measured skin bridge of less than seven centimeters in 85% of instances, the soft tissue complication rate was low in this group of patients. With careful attention to soft tissue management and surgical timing, incisions for plafond fractures may be placed less than seven centimeters apart, allowing the surgeon to optimise exposures based on the pattern of the injury

Purpose: Our aim was to evaluate the use of Ilizarov external fixator for ankle arthrodesis in severe post-traumatic or other ankle arthritis. Patients and Methods: In the period of 8 years, 19 patients underwent ankle arthrodesis with the Ilizarov external fixator for severe ankle arthritis. In four patients the indication for arthrodesis was infection following failed surgical management of tibia plafond fractures, four patients had failed prior ankle arthrodesis and the rest suffered severe ankle arthritis. Eleven patients were male, eight female, with a mean age of 52 years (range 30–71 years). Seven patients had deformities greater then 10°. All had painful stiff ankle joints and 12 patients had disorder of ankle joint anatomy with significant limp. Anterior approach to the ankle joint was preferred, associated with distal fibular osteotomy. Secondary gradual corrections of postoperative deformity and additional compression at the arthrodesis site were performed with the Ilizarov system by closed manipulation. Following frame removal the arthrodesis was immobilised in a cast for a mean of 4 weeks. Results: The mean follow-up period was 3,9 years. A solid ankle arthrodesis was achieved in 18 of the 19 cases. Failure of solid arthrodesis was detected in one patient with insufficient arthroscopic removal of articular cartilage and internal fixation was performed. In one case with major pin tract infection at the distal talus ring distal expansion of the frame was required. According to the Mazur rating system in 12 patients the results were good, in 5 patients fair and in 2 patients poor. Conclusion: The use of Ilizarov external fixator for ankle arthrodesis provides significant interfragmentary compression forces, allows early weight bearing and post-operative adjustment of alignment of arthrodesis. This method should be considered as the treatment of choice in ankle arthrodesis, especially in revision cases and in the cases with infection around of the ankle joint

Primary total knee arthroplasty (TKA) is a reliable procedure with reproducible long-term results. Nevertheless, there are conditions related to the type of patient or local conditions of the knee that can make it a difficult procedure. The most common scenarios that make it difficult are discussed in this review. These include patients with many previous operations and incisions, and those with severe coronal deformities, genu recurvatum, a stiff knee, extra-articular deformities and those who have previously undergone osteotomy around the knee and those with chronic dislocation of the patella.

Each condition is analysed according to the characteristics of the patient, the pre-operative planning and the reported outcomes.

When approaching the difficult primary TKA surgeons should use a systematic approach, which begins with the review of the existing literature for each specific clinical situation.

Cite this article: Bone Joint J 2015;97-B(10 Suppl A):30–9.