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.

Introduction: (OCD) is characterized by bone necrosis and softening of the overlying cartilage, which may separate and displace. It is thought to be secondary to trauma, ischaemia or abnormal epiphyseal ossification. Management remains controversial during the early stages of the disease. Surgery for advanced chondral lesions with loose bodies however remains a challenge. Options that include periosteal graft and autologous chondrocyte transplantation have been used with variable degrees of success. This study investigates the efficacy of these techniques and the use of mesenchymal stem cells to treat advanced chondral lesions found in OCD in animal models.

Materials and Methods: A full thickness articular cartilage defect (6mm long, 3mm wide and 1mm deep) was created in the weight-bearing surface of medial femoral condyle in 22-week old NZW rabbits. A total of 90 knees were randomly divided into 3 groups as follows: 1) Transfer of cultured chondrocytes 2) Transfer of cultured periosteum-derived MSCs and 3) Repair by periosteal graft with their contralateral knees as control. The rabbits were allowed to move freely in their cages. The rabbits were sacrificed at 2, 6, 12, 24 and 36 weeks post-operatively. The healing of the defects was assessed by gross examination and histological grading and subjected biomechanical testing.

Results: Gross and histological examination at 36 weeks post operation (Wakitani et al grading), the mean score for Group 1 is 2.5, Group 2 is 2.3 and Group 3 is 4.5 with control group of 8.9 in terms of cell morphology, matrix staining, surface regularity, thickness of repaired cartilage and integration of cartilage to adjacent host. Biomechanically by indentation test, Group1 had value of 0.22 MPa, Group 2 0.20 MPa, Group 3 0.16 MPa and Control group of 0.12 MPa.

Conclusion: The findings suggested that cultured chondrocytes and mesenchymal stem cells had comparable enhancing effect of the repair of chondral defect in advanced OCD