Aims. Ankle fracture is one of the most common musculoskeletal injuries sustained in the UK. Many patients experience pain and physical impairment, with the consequences of the fracture and its management lasting for several months or even years. The broad aim of ankle fracture treatment is to maintain the alignment of the joint while the fracture heals, and to reduce the risks of problems, such as stiffness. More severe injuries to the ankle are routinely treated surgically. However, even with advances in surgery, there remains a risk of complications; for patients experiencing these, the associated loss of function and quality of life (Qol) is considerable. Non-surgical treatment is an alternative to surgery and involves applying a cast carefully shaped to the patient’s ankle to correct and maintain alignment of the joint with the key benefit being a reduction in the frequency of common complications of surgery. The main potential risk of non-surgical treatment is a loss of alignment with a consequent reduction in ankle function. This study aims to determine whether ankle function, four months after treatment, in patients with unstable ankle fractures treated with close contact casting is not worse than in those treated with surgical intervention, which is the current standard of care. Methods. This trial is a pragmatic, multicentre, randomized non-inferiority clinical trial with an embedded pilot, and with 12 months clinical follow-up and parallel economic analysis. A surveillance study using routinely collected data will be performed annually to five years post-treatment. Adult patients, aged 60 years and younger, with unstable ankle fractures will be identified in daily trauma meetings and fracture clinics and approached for recruitment prior to their treatment. Treatments will be performed in trauma units across the UK by a wide range of surgeons. Details of the surgical treatment, including how the operation is done, implant choice, and the recovery programme afterwards, will be at the discretion of the treating surgeon. The non-surgical treatment will be close-contact casting performed under anaesthetic, a technique which has gained in popularity since the publication of the Ankle Injury Management (AIM) trial. In all, 890 participants (445 per group) will be randomly allocated to surgical or non-surgical treatment. Data regarding ankle function, QoL, complications, and healthcare-related costs will be collected at eight weeks, four and 12 months, and then annually for five years following treatment. The primary outcome measure is patient-reported ankle function at four months from treatment. Anticipated impact. The 12-month results will be presented and published internationally. This is anticipated to be the only pragmatic trial reporting outcomes comparing surgical with non-surgical treatment in unstable ankle fractures in younger adults (aged 60 years and younger), and, as such, will inform the National Institute for Health and Care Excellence (NICE) ‘non-complex fracture’ recommendations at their scheduled update in 2024. A report of long-term outcomes at five years will be produced by January 2027. Cite this article: Bone Jt Open 2024;5(3):184–201

Introduction:. The Best Practice Tariff (BPT) for hip fractures was introduced in April 2010 to promote a number of quality markers, including surgery within 36 hours. We conducted an audit to see whether the introduction of the BPT has had an inadvertent adverse effect on delay to fixation of unstable ankle fractures. Method:. We compared the delay to surgery for 50 consecutive patients with unstable ankle fractures in the 2009 financial year with another 50 patients treated in the 2011 financial year, ie one year after the introduction of the BPT. There were no other changes in service in our department in this period. All radiographs were reviewed and classified using the Lauge-Hansen system by 2 surgeons. Excel was used for data analysis using unpaired T-Test and chi-squared test to assess significance. Results:. 2 patients with pilon fractures were excluded from each group. Demographics and fracture pattern between the remaining 48 patients in each group were similar. The mean delay to surgery before BPT was 2.2 days compared with 3.8 days after its introduction (p = 0.01). 7 patients waited more than 5 days for surgery before BPT compared with 17 patients after its introduction (p < 0.001). There was 1 manipulation under anaesthetic (MUA) before BPT and 8 MUAs in 7 patients after its introduction (p < 0.001). Conclusion:. There is a significant association between the introduction of BPT for hip fractures and an increase in the delay to surgery for patients with unstable ankle fractures by an average of 1.6 days. More patients waited more than 5 days for surgery and there were more MUAs. We postulate that in a resource-limited NHS, prioritizing one patient group inevitably disadvantages others. Orthopaedic trauma services must adapt to national guidance to ensure all patients are treated in a timely fashion

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

Techniques for fixation of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce complications. We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and AAOS Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion. Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture

Impaired vascularity of the skin in elderly ankle fracture patients causes the skin and wound complications. This is part of a RCT comparing ORIF and close contact casting (CCC) for isolated unstable ankle fractures in patients > 60 years. Assessments over 6-months. trans-cutaneous O2 saturation (TcP02) of medial and lateral ankle skin. Ankle-Brachial Pressure Index (ABPI). 3-vessel arterial duplex scan. distal calf perforator artery patency. The uninjured limb was the control. Eighty-nine patients eligible; 59 participated (76% female). 30 randomised to ORIF; 29 to CCC. Each had one death and one withdrawal. Vascular data available on 55. Two patients had delays in wound healing (> 25% for > 6-weeks). Two further developed wound infections. No skin breakdowns in CCC group. There was a reduced TcP02 on day-3 in the injured limb. The TcP02 rose at 6-weeks compared to day-3 (medial 58mmHg; lateral 53mmHg, p=0.002) in the injured leg. At 6-months the TcP02 measurements were not different to uninjured leg. A critical TcP02 (< 20mmHg) found in 4, correlated with skin problems (p=0.003). Two of these had the only major delays in wound healing and one of the two wound infections. 94% of participants had normal ABPI’s (> 1.0). There was no difference between patients with or without an impaired ABPI (< 0.7 mm Hg) and wound problems (p=0.20). There was no difference in patent perforators between the injured and uninjured (p=0.39). Occult vascular insufficiency is present but at low incidence. ABPI and Duplex-US are insensitive for predicting infection or delayed healing. The ankle fracture injury does not disrupt the local perforators. TcPO2 is sensitive and specific for predicting skin problems. Impairment of skin oxygenation is transient. Current TcPO2 technology however is impractical as a clinical tool

Aims. The rationale for exacting restoration of skeletal anatomy after unstable ankle fracture is to improve outcomes by reducing complications from malunion; however, current definitions of malunion lack confirmatory clinical evidence. Methods. Radiological (absolute radiological measurements aided by computer software) and clinical (clinical interpretation of radiographs) definitions of malunion were compared within the Ankle Injury Management (AIM) trial cohort, including people aged ≥ 60 years with an unstable ankle fracture. Linear regressions were used to explore the relationship between radiological malunion (RM) at six months and changes in function at three years. Function was assessed with the Olerud-Molander Ankle Score (OMAS), with a minimal clinically important difference set as six points, as per the AIM trial. Piecewise linear models were used to investigate new radiological thresholds which better explain symptom impact on ankle function. Results. Previously described measures of RM and surgeon opinion of clinically significant malunion (CSM) were shown to be related but with important differences. CSM was more strongly related to outcome (-13.9 points on the OMAS; 95% confidence interval (CI) -21.9 to -5.4) than RM (-5.5 points; 95% CI -9.8 to -1.2). Existing malunion thresholds for talar tilt and tibiofibular clear space were shown to be slightly conservative; new thresholds which better explain function were identified (talar tilt > 2.4°; tibiofibular clear space > 6 mm). Based on this new definition the presence of RM had an impact on function, which was statistically significant, but the clinical significance was uncertain (-9.1 points; 95% CI -13.8 to -4.4). In subsequent analysis, RM of a posterior malleolar fracture was shown to have a statistically significant impact on OMAS change scores, but the clinical significance was uncertain (-11.6 points; 95% CI -21.9 to -0.6). Conclusion. These results provide clinical evidence which supports the previously accepted definitions. Further research to investigate more conservative clinical thresholds for malunion is indicated. Cite this article: Bone Jt Open 2022;3(10):841–849

Introduction: Surgery to ankle fractures requiring fixation is often delayed due to swelling. Social circumstances and surgeon preference dictate whether these patients are rested in hospital or at home. The aim of this study was to explore the effectiveness of a discharge and readmit policy for surgical fixation of ankle fractures unsuitable for immediate surgery.

Materials and methods: The case notes and radiographs of 87 patients’ who underwent ankle fracture fixation between January 1st 2007 and December 31st 2007 were reviewed for causes of delayed surgery and details of the admission.

Results: The sample comprised 46 male and 41 female patents, average age 43 years (range, 13–80). 43 operations were cancelled within 24 hours of admission. These were considered delayed operations. 31 patients were cancelled due to soft tissue swelling. Lack of operating capacity or awaiting the results of further investigations caused the remaining 12 delays. Twenty-three of the delayed procedures were deemed suitable for discharge and re-admission (safe, previously mobile, not living alone). Seven of these patients were discharged and re-admitted through fracture clinic five to seven days later. The remaining 16 were rested as inpatients. Patients treated with traditional inpatient rest and elevation averaged at total inpatient stay of 13 days (range 8–19 days). Patients discharged for rest and elevation had a significantly (p< 0.05) reduced overall inpatient stay of 3.3 days (range, 2–5 days). This approach could have saved our institution an estimated £53,808 (157 inpatient days) for the period January 1st 2007 to December 31st 2007.

Conclusion: The re-admission policy for ankle fractures too swollen for early surgery described in this report significantly reduces overall inpatient stay with no identifiable adverse effects. Readmission through outpatient clinics generates administrative costs and as yet un-quantified service pressure which may cause disruption to outpatient services although this approach in undoubtedly a useful practice with careful patient selection.

The aim of this study was to evaluate the long-term outcomes of patients who had sustained an unstable ankle fracture with a posterior malleolus fracture (PMF) and without (N-PMF). Adult patients presenting to a single academic trauma centre in Edinburgh, UK, between 2009 and 2012 with an unstable ankle fracture requiring surgery were identified. The primary outcome measure was the Olerud Molander Ankle Score (OMAS). Secondary measures included Euroqol-5D-3L Index (Eq5D3L), Euroqol-5D-VAS and Manchester Oxford Foot Questionnaire (MOXFQ). There were 304 patients in the study cohort. The mean age was 49.6 years (16.3–78.3) and 33% (n=100) male and 67% (n=204) female. Of these, 67% (n=204) had a PMF and 33% did not (n=100). No patient received a computed tomography (CT) scan pre-operatively. Only 10% of PMFs (22/204) were managed with internal fixation. At a mean of 13.8 years (11.3 – 15.3) the median OMAS score was 85 (Interquartile Range 60 – 100). There was no difference in OMAS between the N-PMF and PMF groups (85 [56.25 – 100] vs 85 [61.25 – 100]; p = 0.580). There was also no difference for MOXFQ (N-PMF 7 [0 – 36.75] vs PMF 8 [0–38.75]; p = 0.643), the EQ5D Index (N-PMF 0.8 [0.7 – 1] vs PMF 0.8 [0.7 – 1]; p = 0.720) and EQ5D VAS (N-PMF 80 [70 – 90] vs PMF 80 [60 – 90]; p = 0.224). The presence of a PMF does not affect the long-term patient reported outcomes in patients with a surgically managed unstable ankle fracture

Introduction and Objective. Ankle fractures are common and affect young adults as well as the elderly. An unstable ankle fracture treatment typically involves surgical fixation, immobilisation, and modified weight-bearing for six weeks. Non-weight bearing (NWB) cast immobilisation periods were used to protect the soft tissue envelope and osteosynthesis. This can have implications on patient function and may reduce independence, mobility and return to work. Newer trends in earlier mobilisation compete with traditional NWB doctrine, and weak consensus exists as to the best postoperative strategy. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion (ROM) exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates. Materials and Methods. A pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 hours versus non-weight-bearing (NWB) and immobilisation in a cast for six weeks, following ORIF of all types of unstable adult ankle fractures (lateral malleolar, bimalleolar, trimalleolar with or without syndesmotic injury). The exclusion criteria are skeletal immaturity and tibial plafond fractures. The primary outcome measure is the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection (deep and superficial), displacement of osteosynthesis, the full arc of ankle motion (plantar flexion and dorsal flection), RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. Results. We recruited 160 patients with an unstable ankle fracture. Participants’ ages ranged from 15 to 94 years (M = 45.5, SD = 17.2), with 54% identified as female. The mean time from injury to surgical fixation was 1.3 days (0 to 17 days). Patients in the immediate weight-bearing group had a 9.5-point higher mean OMAS at six weeks postoperatively (95% CI 1.48, 17.52) P = 0.021. The complications rate was similar in both groups. The rate of surgical site infection was 4.3%. One patient had DVT, and another patient had a pulmonary embolism; both were randomised to NWB. Length of hospital stay (LOS) was 1 ± 1.5 (0, 12) for the IWB group vs 1.5 ± 2.5 (0, 19) for the NWB group. Conclusions. There is a paucity of quality evidence supporting the postoperative management regimes used most commonly in clinical practice. To our knowledge, immediate weight-bearing (IWB) following ORIF of all types of unstable ankle fractures has not been investigated in a controlled prospective manner in recent decades. In this large multicentre, randomised controlled trial, we investigated immediate weight-bearing following ORIF of all ankle fracture patterns in the usual care condition using standard fixation methods. Our result suggests that IWB following ankle fracture fixation is safe and resulted in a better functional outcome. Once anatomical reduction and stable internal fixation is achieved, we recommend IWB in all types of ankle fractures in a compliant patient

The purpose of this study was to investigate the effectiveness of casting in achieving acceptable radiological parameters for unstable ankle injuries. This retrospective observational cohort study was conducted involving the retrieval of X-rays of all ankles taken over a 2 year period in an urban setting to investigate the radiological outcomes of cast management for unstable ankle fractures using four acceptable parameters measured on a single X- ray at union. The Picture Archiving and Communication System (PACS) was used, the X-rays were measured by a single observer. From the 1st of January 2020 to the 31st of December 2021, a total of 1043 ankle fractures were treated at the three hospitals with a male to female ratio of 1:1.7. Of the 628 unstable ankle injuries, 19% of patients were lost to follow up. 190 were managed conservatively with casts, requiring an average of 4 manipulations, with a malunion rate of 23.2%. Unstable ankle injuries that were treated surgically from the outset and those who failed conservative management and subsequently converted to surgery had a malunion rate of 8.1% and 11.0% respectively. Unstable ankle fractures pose a challenge with a high rate of radiological malunion, regardless of the treatment Casting surgery from the outset or converted to surgery, with rates of 23% and 8% and 11% respectively. In this multivariate analysis we found that conservative management was the only factor influencing the incidence of malunion, age, sex and type of fracture did not have a scientific significant influence

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

Introduction. Following publication of the Ankle Injury Management (AIM) trial in 2016 which compared the management of ankle fractures with open reduction and internal fixation (ORIF) versus closed contact casting (CCC), we looked at how the results of this study have been adopted into practice in a trauma unit in the United Kingdom. Methods. Institutional approval granted to identify eligible patients from a trauma database. 143 patients over 60 years with an unstable ankle fracture between 2017 and 2019 (1 year following publication of the AIM trial) were included. Open fractures, and patients with insulin-dependent diabetes or peripheral vessel disease were excluded (as per AIM criteria). Radiographs were reviewed for malunion and non-union. Clinical notes were reviewed for adverse events. Minimum follow up was 24 months. Results. Of the 143 patients, 42 patients (29.4%) received a moulded cast with a return to theatre rate of 21.4%, malunion rate of 30.1%, and infection or wound problem rate of 4.8%. When the exact phrase “close contact cast” was specified in 21 patients (14.7%), there was a 19.0% return to theatre rate, 28.6% malunion rate, and a 4.8% infection or wound problem rate. 101 patients (70.6%) had ORIF with a return to theatre rate of 10.9%, malunion rate of 5.0%, and infection or wound problem rate of 13.9%. Discussion. Our results show a high rate of complication with cast management of unstable ankle fractures in this older population. This was improved where CCC was specified, but remains higher even than those published in the AIM trial. Whilst there is certainly a role for CCC in carefully selected patients, we would advise caution in the widespread adoption of a close contact casting technique

Abstract. Objectives. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates. Methods. A pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 hours versus NWB and immobilisation in a cast for six weeks, following ORIF of all types of unstable adult ankle fractures. The exclusion criteria are skeletal immaturity and tibial plafond fractures. The primary outcome measure is the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection, displacement of osteosynthesis, the full arc of ankle motion, RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. Results. We recruited 160 patients with an unstable ankle fracture. Participants’ ages ranged from 15 to 94 years (M = 45.5, SD = 17.2), with 54% identified as female. The mean time from injury to surgical fixation was 1.3 days (0 to 17 days). Patients in the IWB group had a 9.5-point higher mean OMAS at six weeks postoperatively (95% CI 1.48, 17.52) P = 0.021 with a similar result at three months. The complications rate was similar in both groups. The rate of surgical site infection was 4.3%. One patient had DVT, and another patient had a PE, both were randomised to NWB. Length of hospital stay was 1 ± 1.5 (0, 12) for the IWB group vs 1.5 ± 2.5 (0, 19) for the NWB group. Conclusion. In this large multicentre RCT, we investigated WB following ORIF of all ankle fracture patterns in the usual care condition using standard fixation methods. Our result suggests that IWB following ankle fracture fixation is safe and resulted in a better functional outcome

Introduction: Operative fixation of unstable ankle fractures is a well-recognised form of management. However controversy exists in the surgical treatment of unstable ankle fractures in the elderly age group, over 80 years. Operative fixation in these cases is challenging and the postoperative mortality and morbidity has discouraged surgical intervention. The literature regarding the prognosis of surgery in this elderly group is limited. The purpose of this study is to document the results of operative fixation of unstable ankle fractures in patients aged over 80 years of age. Methods: Ninety-two consecutive patients aged above 80 underwent open reduction and internal fixation of unstable ankle fractures during the period of January 1998 to August 2007. Five patients’ case records were unavailable for the study and they were therefore excluded. The data was collected retrospectively from the case records and radiographs. The clinical and radiological outcomes following surgery were recorded and analysed in detail. The complications were noted and the risk factors for poor prognosis were analysed. Results: The average age was 85.2 (range 80.1 – 95.1 yrs). The minimum duration of follow up was nine months. The superficial wound infection rate was 5.7% (5 cases). The deep infection rate was 4.6% (4 cases), three required surgical debridement. The 30-day postoperative mortality was 4.6 % (4 cases). 88.1 % (74 out of 84 cases) were able to return to their preinjury mobility at the last follow-up. Diabetes and smoking did not statistically influence the outcome of the surgery. Conclusion: The results of operative fixation of unstable ankle fractures in this age group are encouraging with good functional recovery and return to preinjury mobility status in most cases

A number of classification systems exist for posterior malleolus fractures of the ankle. The reliability of these classification systems remains unclear. The primary aim of this study was to evaluate the reliability of three commonly utilised fracture classification systems of the posterior malleolus. 60 patients across 2 hospitals sustaining an unstable ankle fracture with a posterior malleolus fragment were identified. All patients underwent radiographs and computed tomography of their injured ankle. 9 surgeons including pre-ST3 level, ST3-8 level, and consultant level applied the Haraguchi, Rammelt, and Mason & Molloy classifications to these patients, at two timepoints, at least 4 weeks apart. The order was randomised between assessments. Inter-rater reliability was assessed using Fleiss’ kappa and 95% confidence intervals (CI). Intra-rater reliability was assessed using Cohen's Kappa and standard error (SE). Inter-rater reliability (Fleiss’ Kappa) was calculated for the Haraguchi classification as 0.522 (95% CI 0.490 – 0.553), for the Rammelt classification as 0.626 (95% CI 0.600 – 0.652), and the Mason & Molloy classification as 0.541 (95% CI 0.514 – 0.569). Intra-rater reliability (Cohen's Kappa) was 0.764 (SE 0.034) for the Haraguchi, 0.763 (SE 0.031) for the Rammelt, 0.688 (SE 0.035) for the Mason & Molloy classification. This study reports the inter-rater and intra-rater reliability for three classification systems for posterior malleolus fractures. Based on definitions by Landis & Koch (1977), inter-rater reliability was rated as ‘moderate’ for the Haraguchi and Mason & Molloy classifications; and ‘substantial’ for the Rammelt classification. Similarly, the intra-rater reliability was rated as ‘substantial’ for all three classifications

Introduction: Operative fixation of unstable ankle fractures is a well recognised form of management. However controversy exists in the surgical treatment of unstable ankle fractures in the very elderly age group of over 80 years. Operative fixation in these cases is challenging and the postoperative mortality and morbidity has discouraged surgical intervention in this population. However, the literature regarding the prognosis of surgery in this elderly group is very limited. The purpose of our study was to describe the results of 85 patients aged above 80 years, who underwent operative fixation for unstable ankle fractures. Methods: 92 consecutive patients aged above eighty years of age had open reduction and internal fixation for unstable ankle fractures during the period of January 1998 – August 2007. The data was collected retrospectively from the case records and radiographs. The mechanism of injury, fracture pattern, and medical co morbidities were recorded. A standard postoperative rehabilitation programme was followed. 5 patients were excluded as complete medical records were unavailable. The clinical and radiological outcomes following surgery were recorded and analysed in detail. The complications were noted and the risk factors for poor prognosis were analysed. Results: There were 71 women and 16 men in the study. The most common fracture pattern was pronation external rotation type. The average age was 85.2 (Range 80.1 – 95.1 yrs). The minimum duration of follow up was 9 months. The superficial wound infection rate was 5.7% (5 cases) which settled with oral antibiotic treatment for 1–2 weeks. The deep infection rate was 4.6% (4 cases) which required surgical debridement and implant removal. The 30 day postoperative mortality was 4.6 % (4 cases). Most patients demonstrated radiological fracture union with medial malleolus possessing slightly a higher risk of non union. 88.1 % (74 out of 84 cases) were able to return back to their pre injury mobility at the last follow-up. Diabetes and smoking did not statistically influence the outcome of the surgery. Conclusion: The results of operative fixation of unstable ankle fractures are very encouraging with good functional recovery and return to pre injury mobility status in most cases. The surgical fixation is technically challenging and careful attention must be given to the osteopenia and soft tissue factors

To compare the long-term outcomes of fibular nailing and plate fixation for unstable ankle fractures in a cohort of patients under the age of 65 years. Patients from a previously conducted randomized control trial comparing fibular nailing and plate fixation were contacted at a minimum of 10 years post intervention at a single study centre. Short term data were collected prospectively and long-term data were collected retrospectively using an electronic patient record software. Ninety-nine patients from one trauma centre were included (48 fibular nails and 51 plate fixations). Groups were matched for gender (p = 0.579), age (p = 0.811), body mass index (BMI)(p = 0.925), smoking status (p = 0.209), alcohol status (p = 0.679) and injury type (p = 0.674). Radiographically at an average of 2 years post-injury, there was no statistically significant difference between groups for development of osteoarthritis (p = 0.851). Both groups had 1 tibio-talar fusion (2% of both groups) secondary to osteoarthritis with no statistically significant difference in overall re-operation rate between groups identified (p = 0.518,). Forty-five percent (n=42) of patients had so far returned patient reported outcome measures at a minimum of 10 years (Fibular nail n=19, plate fixation n=23). No significant difference was found between groups at 10 years for the Olerud and Molander Ankle Score (p = 0.990), the Manchester-Oxford Foot Questionnaire (p = 0.288), Euroqol-5D Index (p = 0.828) and Euroqol-5D Visual Analogue Score (p = 0.769). The current study illustrates no difference between fibular nail fixation and plate fixation at a long-term follow up of 10 years in patients under 65 years old, although the study is currently under powered

Introduction. Ankle fractures represent approximately 10% of the fracture workload and are projected to increase due to ageing population. We present our 5 years outcome review post-surgical management of ankle fractures in a large UK Trauma unit. Methods. A total of 111 consecutive patients treated for an unstable ankle fracture were entered into a database and prospectively followed up. Baseline patient characteristics, complications, further intervention including additional surgery, functional status were recorded during five-year follow-up. Pre-injury and post-fixation functional outcome measures at 2-years were assessed using Olerud-Molander Ankle Scores (OMAS) and Lower Extremity Functional Scales (LEFS). A p value < 0.05 was considered significant. Results. The mean age was 46 with a male:female ratio of 1:1.1. The distribution of comorbidities was BMI >30 (25%), diabetes (5%), alcohol consumption >20U/week (15%) and smoking (26%). Higher BMI was predictive of worse post-op LEFS score (p = 0.02). Between pre-injury and post fixation functional scores at 2 years, there was a mean reduction of 26.8 (OMAS) and 20.5(LEFS). Using very strict radiological criteria, 31 (28%) had less than anatomical reduction of fracture fragments intra-operatively. This was, however, not predictive of patients' functional outcome in this cohort. Within 5-year period, 22 (20%) patients had removal of metalwork from their ankle, with majority 13 (59%) requiring syndesmotic screw removal. Further interventions included: joint injection (3), deltoid reconstruction (1), arthroscopic debridement (1), superficial sinus excision (2), and conversion to hindfoot nail due to failure of fixation (1). Reduction in OMAS was predictive of patients' ongoing symptoms (p=0.01). Conclusion. There is a significant reduction in functional outcome after ankle fracture fixation and patients should be counselled appropriately. Need for removal of metalwork is higher in patients who require syndesmosis stabilisation with screw(s)

Background. Studies have compared open reduction internal fixation (ORIF) with fibular nail fixation (FNF) and shown reduced wound complications with minimal difference to PROMS in the short term. Our aim is to compare long-term outcomes for unstable ankle fractures at 10 year follow up. Methods. Patients from a previously conducted RCT were contacted at a minimum of 10 years post intervention at a single study centre. Case notes were reviewed, and patient reported outcome measures acquired at 10 years. Results. Ninety-nine patients were included (48 FNF and 51 ORIF). After 10 years 75% (33/44) of patients in the FNF group required no further follow up versus 81% (39/48) in the ORIF group. Radiographically at 2 years post-injury, there was no statistically significant difference between groups for development of osteoarthritis (p=0.851). There was one tibio-talar fusion in each group secondary to osteoarthritis, but no statistically significant difference in overall re-operation rate (p=0.518). Fifty-one percent (n=50) of patients have so far returned patient reported outcome measures at a minimum of 10 years (Fibular nail n=23, plate fixation n=27). No significant difference was found between groups for the mean scores of Olerud and Molander Ankle Score (FNF 84.78 vs ORIF 84.07; p=0.883), the Manchester-Oxford Foot Questionnaire (MOXFQ) (FNF 89.54 vs ORIF 96.47; p=0.112), Euroqol-5D Index (FNF 0.88 vs ORIF 0.87; p=0.701) and Euroqol-5D Visual Analogue Score (FNF 77.30 vs ORIF 77.52; p=0.859). Conclusion. The current study illustrates that both methods of treatment result in a satisfactory long-term outcome with no difference in late complications or PROM scores at up to 10 years in patients under 65 years old, although the study is currently under powered

Is Non-Weight-Bearing Necessary? (INWN) is a pragmatic multicentre randomised controlled trial comparing immediate protected weight-bearing (IWB) with non-weight-bearing cast immobilisation (NWB) following ankle fracture fixation (ORIF). This trial compares; functional outcomes, complication rates and performs an economic analysis to estimate cost-utility. IWB within 24hrs was compared to NWB, following ORIF of all types of unstable ankle fractures. Skeletally immature patients and tibial plafond fractures were excluded. Functional outcomes were assessed by the Olerud-Molander Ankle Score (OMAS) and RAND-36 Item Short Form Survey (SF-36) taken at regular follow-up intervals up to one year. A cost-utility analysis via decision tree modelling was performed to derive an incremental cost effectiveness ratio (ICER). A standard gamble health state valuation model utilising SF-36 scores was used to calculate Quality Adjusted Life Years (QALYs) for each arm. We recruited 160 patients (80 per arm), aged 15 to 94 years (M = 45.5), 54% female. Complication rates were similar in both groups. IWB demonstrated a consistently higher OMAS score, with significant values at 6 weeks (MD=10.4, p=0.005) and 3 months (MD 12.0, p=0.003). Standard gamble utility values demonstrated consistently higher values (a score of 1 equals perfect health) with IWB, significant at 3 months (Ẋ = 0.75 [IWB] / 0.69 [NWB], p=0.018). Cost-utility analysis demonstrated NWB is €798.02 more expensive and results in 0.04 fewer QALYs over 1 year. This results in an ICER of −€21,682.42/QALY. This negative ICER indicates cost savings of €21,682.42 for every QALY (25 patients = 1 QALY gain) gained implementing an IWB regime. IWB demonstrates a superior functional outcome, greater cost savings and similar complication rates, compared to NWB following ankle fracture fixation