Between October 2006 and September 2007, eight consecutive patients with syndesmotic diastasis of the ankle had Tight Rope suture –endobutton fixation. We present our early results following this fixation. There were 3 males and 5 females with a mean age of 42 years (range 21 – 67). All were followed up for a mean of 7 months. Five patients had right side involvement. Majority were twisting injuries. These patients were compared with a cohort group (10 patients) who had diastasis screw fixation for similar fractures during the same period. Results: The mean post operative Olerud & Molander ankle subjective score was 86 points. The tourniquet time was significantly less in endobutton group compared to the diastasis screw group(mean of 56 minutes vs. 72 minutes). There was some difference in time to mobilisation between the two groups (mean of 10 days). The endobutton group patients were able to return to work and leisure activities earlier (mean of 4 weeks) compared to the diastasis group. Range of motion was similar in both groups. There were fewer complications in both groups with superficial infection and stiffness being the most common. Both groups were satisfied with the fixation. Advantages of Tight rope fixation: The tourniquet time was reduced; there was no need for 2nd operation with its attendant risks. Earlier mobilisation was possible leading to early return to work and leisure activities. We recommend the use of this new suture endobutton fixation for ankle diastasis with promising early functional results. Further prospective studies are needed to evaluate this new type of fixation device

Flexible fixation techniques combined with anatomic (open) syndesmosis reduction have demonstrated improved functional outcomes and rates of malreduction. Suture-button devices allow physiologic motion of the syndesmosis without need for implant removal, which may lower the risk of recurrent syndesmotic diastasis. There is limited longer-term assessment of the maintenance of reduction between static and flexible syndesmotic fixation using bilateral ankle CT evaluation. This is an a priori planned subgroup analysis of a multi-centre, randomized clinical trial comparing static syndesmosis fixation (two 3.5 mm screws) with flexible fixation (single knotless Tightrope) for patients with AO- OTA 44-C injuries. Patients who completed bilateral ankle CT scans at 3- and 12-month follow-up were included. The primary outcome measure was syndesmotic malreduction based on bilateral ankle CT scans, using the uninjured, contralateral ankle as a control. Anterior (ASD), middle (MSD), and posterior (PSD) syndesmosis distance were calculated to measure syndesmosis reduction. Secondary outcomes included re-operation, adverse events and functional outcomes including the EQ5D, Olerud-Molander Ankle Score (OM), Foot and Ankle Disability Index (FADI), and Work Productivity Activity Impairment Questionnaire (WPAI). Paired samples t-tests were used to compare injured to control ankles (R, v 3.5.1). 42 patients (24 Group S, 18 Group T) were included. ASD for Group T was 5.22mm (95%CI 4.69–5.77) at 3 months compared to 4.26mm (95%CI 3.82–4.71; p=0.007) in controls and 5.38mm (95%CI 4.72–6.04) at 12 months compared to 4.44mm (95%CI 3.73–5.16; p=0.048) in controls. ASD for Group S was 4.63mm (95%CI 4.17– 5.10) at 3 months compared to 4.67mm (95%CI 4.24–5.10; p=0.61) in controls, but significantly increased to 5.73mm (95%CI 4.81–6.66) at 12 months compared to 4.65mm (95%CI 4.15–5.15; p=0.04) in controls. MSD results were similar; Group T had a larger MSD than control ankles at 3 months (p=0.03) and 12 months (p=0.01), while the MSD in Group S was not different at 3 months (p=0.80) but increased at 12 months (p=<0.01). 88% (21/24) of Group S had broken or removed screws by 12 months. Unplanned re-operation was 15% in Group S and 4% in Group T (p=0.02), with an overall re-operation rate of 30% in Group S. There was no significant difference between treatment groups for EQ-5D, OM, FADI or WPAI at 3- or 12-month follow-up. Tightrope fixation resulted in greater diastasis of the ASD and MSD compared to contralateral, uninjured ankles at 3- and 12-months post-fixation. Group S initially had syndesmotic reduction similar to control ankles, but between 3- and 12-months post-fixation, there was significantly increased syndesmosis diastasis compared to controls. The majority of Group S (88%) had either broken screws or scheduled screw removal, which may explain the increased tibio-fibular diastasis seen at 12-months

Aims: We aimed to evaluate diagnostic contribution of MRI-Arthrography in syndesmosis disruption at ankle fractures. Methods: 18 patient who had Denis Weber type B-C fractures and are suspected to have syndesmotic diastasis considering tibiofibular clear space and tibiofibular overlap measurments in conventional radiographs are assesed with MRI followed by MRI-Arthrography. Because joint fluid was already seen in tibiofibular space in 3 patients at MRI, MRI-Arthrography was performed for the remaining 15 patients. If there was a changes between the results obtained from MRI and the results obtained after MRI-arthrography was tested istatistically. Convantional radiographs, MRIs and MRI-Arthrographies were analysed by 2 independent observers and interobserver concordance was assesed. Following intraoperative observation and asssesment syndesmotic diastasis was treated considering radiographic and MRI-arthrographic results. Results: In 15 cases who were regarded to have syndesmotic diastasis according to conventional radiographies, 8 (53.3%) diastasis were confirmed with only MRI and 12 (80%) diastasis were confirmed with MRI arthrography. Following intraoperative assesment 13 (86.6%) cases were regarded to have diastasis and surgical intervention was performed for diastasis repair. In 2 (13.3%) cases surgical intervention for diastasis repair was not performed. If there was a change in decission after MRI and after MRI-arthrography is analysed with chi-square test between related groups. There were statistically significiant difference (p< 0.05) in these means. There is interobserver concordance in conventional radiographic, MRI-arthrographic assesments and in assesments for ATIF and PTIF seperately inMRI.(p< 0.001). Conclusion: These results suggest that conventional radiography and MRI is not sufficient in assesing syndesmosis and MRI-arthrography is important for diagnosis

Background. Tightrope fixation has been suggested as an alternative to screw stabilisation for distal tibiofibular joint diastasis that provides stability but avoids the problems of rigid screws across the joint. Recent case series (of 6 and 16 patients) have however, reported soft tissue problems and infections in 19–33% of patients. This study aims to review treatment and complications of distal tibiofibular diastasis fixation in our unit with the use of Tightrope or diastasis screws. Methods. Retrospective review of all patients undergoing primary ankle fixation between May 2008 and October 2009. Exclusions included revision procedures, or ankle fixation prior to the current fracture. Those undergoing Tightrope or diastasis screw fixation were studied for any complications or further procedures. Clinical records and XRAYs were reviewed, family practitioners of the patients were contacted and any consultations for ankle related problems noted. Results. 187 primary ankle fixation procedures were performed. 35 ankles required stabilisation of the distal tibiofibular joint. In 12, this was achieved using the Tightrope and in 23, syndesmotic screws were used. There was no difference in the adequacy of reduction in the two groups. Of those stabilised with a Tightrope, 6 were Maisonneuve injuries, 5 Weber C and 1 Weber B. 1 was lost to followup. Of the remaining 11, none had complications attributable to the method of fixation documented in hospital or family practitioner records. One had a small stitch abscess that settled on removal of the suture material. None underwent subsequent procedures. Of 23 stabilised with screws, 4 were Weber B, 14 Weber C, 4 Maisonneuve and 1 syndesmotic injury associated with an isolated posterior malleolus fracture. In this group of patients with primary ankle fixation involving a diastasis screw there was 1 deep infection requiring removal of metalwork, 1 superficial wound infection after syndesmotic screw removal and 1 wound breakdown after syndesmotic screw removal. A patient developed superficial peroneal nerve palsy at operation and 1 syndesmotic fixation failed and underwent revision surgery. This patient subsequently developed infection and had revision to a hindfoot nail. 19 patients underwent screw removal. The 23 patients underwent 45 procedures (mean 1.96 procedures per patient). Conclusion. In a consecutive series of 187 ankle procedures, 12 had the distal tibiofibular joint stabilised with a Tightrope with no noted complications attributable to the implant and no additional procedures. 23 patients underwent diastasis screw fixation with 19 screw removal procedures and 5 complications of various severity, 2 of which were attributable to screw removal. Tightrope fixation has provided stable fixation of the injured syndesmosis in our unit and we have not to date encountered complications previously described in the literature

Purpose: Maisonneuve fracture is a rare variant of malleolar fractures. Standard surgical care is not well defined. We performed a retrospective analysis of operated patients to propose a system to determine adequate care as a function of the type of lesions observed. Material and methods: This retrospective analysis involved 20 patients who underwent surgery for Mai-sonneuve fracture between 1989 and 2000. Mean age was 42 years at surgery. Male gender predominated (16 patients). Seven patients (group 1) were treated without a syndesmodesis screw (osteosynthesis of the medial malleolus in six cases and suture of the medial collateral ligament in one). Thirteen patients (group 2) were treated via a first lateral approach and a syndesmodesis screw followed by a complementary medial approach in seven cases (two cases of medial malleolus osteocynthesis and five cases of medial collateral ligament suture). The Duquennoy functional score was determined at last follow-up. Quality of the reduction and presence of degenerative disease were determined on standard x-rays and computed tomographies. Results: Mean follow-up was four years nine months (range 1–10 years). No case of tibiotalar diastasis was observed at at least one year. Among the five patients reviewed clinically, outcome was excellent in four and fair in one. In group 2 (syndesmodesis), we found two cases of residual diastasis and two cases of tight syndesmosis at at least one year. Among the nine patients reviewed clinically, outcome was excellent in three and fair or poor in six. Discussion: This retrospective analysis collaborates the few data in the literature on Maisonneuve fractures. Ligament injury has varied greatly (with or without tear of the medial lateral ligament, more or less full thickness rupture of the interosseous membrane). In our experience, it is always difficult to reduce the diastasis via the primary lateral approach. Conversely, the primary medial approach has, after testing, enabled eliminating the syndesmodesis screw, with its recognised deleterious effects, in seven cases. Conclusion: Due to the diversity of the ligament injuries encountered in patients with Maisonneuve fractures, we have adopted the following surgical strategy. If there is diastasis, after confirmation of any injury to the medical compartment, medial approach to suture the medial collateral ligament or osteosynthesis of the medial malleolus: in the case of diastasis reduction, we advocate a syndesmodesis screw; if diastasis persists, a secondary lateral approach is useful to reduce the medial malleolar rotation and insert a syndesmodesis screw

Circumferential pelvic binders have been developed to allow rapid closure of the pelvic ring in unstable fracture patterns. Despite evidence to support the use of pelvic binders, there is a paucity of clinical data regarding the effect of binder position on symphyseal diastasis reduction. All patients presenting to the UK's military hospital in Afghanistan who survived and underwent pelvic radiography were reviewed. Cases were identified by retrospective assessment of all digital plain pelvic radiographs performed between January 2008 and July 2010. All radiographs and CT images were assessed to identify the presence of any pelvic fracture. Patients were grouped into three categories according to the vertical level of the buckle: superior to the trochanters (high), inferior to the trochanters (low) and at the level of the trochanters (troch). Diastasis reduction was measured in patients with Anterior-Posterior Compression (APC) grades II and III, or Combined Mechanical Injuries(CMI). Comparison of diastasis reduction between the high and troch groups was assessed by an independent samples Student's t-test. We identified 172 radiographs where the metallic springs in the buckle of a SAM Pelvic Sling. ™. were clearly visible. The binders were positioned at the trochanteric level in 50% of radiographs. A high position was the commonest site of inaccurate placement (37%). In the patients with fractures and an open diastasis, the mean pelvic diastasis gap was 2.75 times greater in the high group compared to the trochanteric level (mean difference 22 mm) (p < 0.01). Application of pelvic binders superior to the greater trochanters is commonplace and associated with inadequate fracture reduction, which is likely to delay cardiovascular recovery in these significantly injured casualties

Percutaneous fixation of syndesmosis is an accepted treatment of isolated Weber C fractures of the ankle. However, the status of syndesmosis after removal of the screws has never been studied to our knowledge. We studied eight patients for any residual diastasis and its clinical significance. CT scan was used to study the residual diastasis of syndesmosis after the removal of screws by comparing with the normal side. Patients were clinically assessed using Maryland and International Foot Scoring systems. The talocrural angles were measured and were compared with the normal side. Ten patients of isolated Weber C fractures were treated with percutaneous application of syndesmotic position scres from November ’97 to July ’99. Eight were available for follow up and two were lost to follow up. The average follow up was 427.9 days (14.26 months) with a range 167–744 days. There were 7 males and 3 females. The average age was 32.2 years (range 17–66). Left side was involved in 6 cases and right side in 4. The scres were removed after an average period of 78.3 days (11.8 weeks) with a range of 45–189 days. All patients were found to be having diastasis ranging from 1 mm to 3 mm with an average of 2.06 mm. The Maryland score ranged from 76 to 100 with an average of 90. The international score ranged from 78 to 100 with an average of 87.62. The diastasis roughly paralleled with the Foot scores. All patients who had percutaneous fixation of syndesmosis had residual diastasis following removal of the screws and this may be clinically significant

Introduction. Syndesmosis injuries are significant injuries and require anatomical reduction. However, stabilisation of these injuries with syndesmosis screws carries specific complications and many surgeons advocate a second operation to remove the screw. Primary Tightrope suture fixation has been shown to be an effective treatment for syndesmotic injuries and avoids the need for a second operation. Materials and Methods. A retrospective audit identified patients who were treated for syndesmosis injuries over a two year period. Theatre and clinic costs were obtained to compare the cost of syndesmosis fixation using diastasis screws with the estimated cost of primary syndesmosis fixation using a Tightrope suture. Results. 79 patients received diastasis screw fixation of syndesmosis injuries between January 2007 and January 2009. The mean number of follow up clinic appointments was 3.7 following initial surgery, and 2.2 following diastasis screw removal. Allowing for device, theatre time and clinic appointment costs, and an estimated average of 4 follow up appointments following Tightrope syndesmosis fixation, primary fixation with this device could a saving of 34 theatre slots, 68 outpatient clinic appointments, and £12,138 per year at our hospital. Discussion. Biomechanical studies have demonstrated a reduction in normal tibiotalar external rotation with the presence of a diastasis screw, and there are several published reports of complications when these screws are retained. The Tightrope suture provides reduction of the syndesmosis whilst allowing normal physiological movement at the distal tibiofibular joint and negates the need for a second operation to remove the implant. In addition there may be improvements in foot and ankle scores and a faster return to work when these devices are used compared with traditional screw fixation. Conclusion. In addition to the patient benefits, our audit suggests that there may be significant financial benefits associated with primary syndesmosis fixation with Tightrope sutures

Introduction A new technique of ankle syndesmosis fixation is proposed. Buttons are placed on both sides of the ankle, connected by a strong non-absorbable suture. The technique is simple and minimally invasive: a medial incision is not required. It resists diastasis whilst allowing physiological micromotion and does not require routine removal. Methods The technique was tested on a cadaver model of a Maisonneuve injury under increasing torque loads. Sixteen embalmed cadaver legs were randomised to receive suture-button fixation or four-cortical 4.5 mm syndesmosis screw fixation. A prospective clinical study involving 16 patients with Weber C fractures and syndesmosis diastasis is presented. They underwent suture-button fixation and the results were compared to 16 consecutive patients with syndesmosis screw fixation. Results In the cadaver study, both groups had similar rates of diastasis following torque loading. However, the suture-button did give a more consistent performance: standard deviations were significantly lower (p=0.001) than the screw group. In the clinical study, both groups were evenly matched as regards patient age, male: female ratio, and fracture patterns. Mean AOFAS ankle outcome scores at three months were significantly better in the suture-button group (91 versus 82, p=0.01). No suture-button patients required implant removal. They had a faster return to work compared to the screw group (three months versus five months). Axial CT scanning performed at three months post-op showed all implants to be intact with no loss of reduction. Conclusions Suture-button syndesmosis fixation is simple, safe, effective and physiological. It has shown improved outcomes and faster rehabilitation, without needing routine removal. It may become the treatment of choice in Weber C ankle fractures with a syndesmosis diastasis. In relation to the conduct of this study, one or more the authors have received, or are likely to receive direct material benefits

Introduction. Previous studies have demonstrated the need of accurate reduction of ankle syndesmosis. Measurement of syndesmosis is difficult on plain radiographs. Recently, a difference of 2mm in anterior and posterior measurements at incisura of the inferior tibio-fibular joint on CT has been described as a measure of malreduction (depicted as ‘G’ for ease of description). Our practice changed towards routine post operative bilateral CT following syndesmosis fixation to assess the reduction and identify potential problems at an early stage. The aim of this primarily radiological study was to determine if the use of bilateral cross sectional imaging brings additional benefit above the more conventional practice of unilateral imaging. Method. Between 2007 and 2009, nineteen patients with ankle fractures involving the syndesmosis were included in the study group who had bilateral CT post operatively. The values of ‘G’ and the mean diastasis (MD) were calculated, representing the average measurement between the fibula and the anterior and posterior incisura. Results. When compared to the normal side, eight out of nineteen (42%) cases were found to have a residual diastasis even after fixation across the syndesmosis, However, if a standard value of G(2mm) was used for the injured leg only, all of the nineteen cases would have abnormal values of ‘G’ following reduction. The value of G for the injured side was poorly correlated with the mean inter-limb diastasis (MD, R=0.23). Discussion. Our study has clearly demonstrated the need for individualising the assessment method to guide surgeons and radiologists prior to revision surgery. A standard value of ‘G’ of 2mm as the normal limit cannot be applied universally as apparent from the data presented in this study

Introduction: Several methods for the management of syndesmosis disruption during ankle fracture fixation have been documented The Tightrope anchor is a relatively new technique consisting of two buttons and a strand of Fiber-wire which is looped twice though the buttons to create a pulley effect between the fibula and tibia, thereby stabilising the ankle syndesmosis. We have reviewed the outcomes in 38 patients treated with this technique. Materials and Methods: Data including nature of operation, complications and the need for subsequent surgery were recorded for all patients receiving a Tightrope from May 2006 to September 2008. Results: The mean patient age was 35 years, and 23 were male. 30/38 patients required no further surgery and had a good functional outcome. Two patients had prominent fibula plates removed but achieved good functional outcomes. For one patient a Tightrope was performed following diastasis screw failure: an improved but suboptimal outcome was achieved. A patient with fibromyalgia had a good range of movement but complained of discomfort. One patient with Poland sequence, who fell post operatively, needed tightrope removal and syndesmosis debridement resulting in a good but painful range of movement. Another patient developed a pulmonary embolus following surgery and prolonged swelling and discomfort limited her functional capacity. Two patients required tightrope removal and significant wound debridement following osteomyelitis of the fibula and tibia. Discussion and Conclusion: The Tightrope is an effective method of ankle syndesmosis repair, with a reduced need for subsequent diastasis related surgery (35/38) when compared to our diastasis screw method (100%). However, our significant rate of osteomyelitis is disturbing, warranting further investigation

Introduction: Ankle diastasis injury occurs in up to 20% of ankle fractures. Various techniques have been used to treat syndesmosis injuries, but controversy remains and outcome is variable. In light of some recent cases of substandard syndesmosis fixations requiring revision, an audit of our results was undertaken. Method: Study type: Retrospective audit of radiographs and patient records. Data collection: patients were selected using an orthopaedic database search for operations coded as distal tib/fib ORIF or ankle ORIF. Study period: 12 months, July 2008 to July 2009 (currently data has been analyzed on the first 6 months only, the remaining 6 months will follow). Audit questions to be answered: How is ankle diastasis injury being managed? Are we reducing syndesmosis correctly? Should there be a revision to local policy?. Audit standard: Syndesmoses should be adequately reduced and fixation techniques employed should be in accordance with recommendations in standard Orthopaedic reference texts (Rockwood & Green, AO fixation manual 3). Results: 76 ankle ORIFs in July to December 2008 inclusive. Out of these, 16 had diastasis fixation (21%). 2 of the patients had a syndesmosis width over 6 mm indicating an inadequate reduction of the syndesmosis 1. Both of these required revision surgery. In total 70% of the post operative x-rays showed inadequate syndesmosis fixation or reduction. Discussion: The single most predictive indicator of a favourable function is accurate reduction of the syndesmosis 2. Substandard fixations are associated with poor long term outcomes. This raises the potential for litigation and the requirement for education and policy change. We have produced policy guidelines for theatre and circulated the information to all surgeons. A further audit will be carried out to assess the effectiveness of this in 6 months time. (The data will be available from this re-audit for presentation at the conference.)

The radiological evidence of implant failure following plate fixation of traumatic pubic symphysis diastasis can be up to 75%. We report the complications following symphyseal double orthogonal plating in patients with pubic symphysis diastasis over a period of 2.5 years. Patient records and radiographs of 38 consecutive patients were reviewed with mean follow up of 12.5 months. 5 patients (13%) had radiological evidence of implant failure with one patient (2.6%) requiring revision surgery. There was no evidence of wound complications. We conclude that our lower rate of revision surgery and metal work failure is attributed to double orthogonal plating

Traditionally, unstable anterior pelvic ring injuries have been stabilised with an external fixator or by internal fixation. Recently, a new percutaneous technique of placement of bilateral supraacetabular polyaxial screws and subcutaneous connecting bar to assemble an “internal fixator” has been described. We present the surgical technique and early clinical results of using this technique in twenty-five consecutive patients with a rotationally unstable pelvic ring injury and no diastasis of the symphysis pubis treated between April 2010 and December 2013. Additional posterior pelvic stabilisation with percutaneous iliosacral screws was used in 23 of these patients. The anterior device was routinely removed after three months. Radiological evidence of union of the anterior pelvic ring was seen in 24 of 25 patients at a minimum 6 month follow-up. Thirteen patients developed sensory deficits in the lateral femoral cutaneous nerve (five bilateral) and only one fully recovered. The anterior pelvic internal fixator is a reliable, safe and easy percutaneous technique for the treatment of anterior pelvic ring injuries, facilitating the reduction and stabilisation of rotational displacement. However, lateral femoral cutaneous nerve dysfunction is common. The technique is recommended in cases with bilateral or unilateral pubic rami fractures and no diastasis of the symphysis pubis

Tunning fork lines (TFL) were drawn on ankle anterior-posterior radiographs to assess the talar shift in ankle fractures. A 3-D ankle joint reconstruction was prepared by mapping normal ankle joint using auto CAD in 1997. TFL were drawn using normal anatomical landmarks on saggital, coronal and transverse planes. The ankle joint anatomical relationship with talus was studied in various rotation simulating radiographic anterior-posterior views and talar shift was studied. Between 2006 and 2012 on antero-posterior view of ankle radiographs and PACS, TFL were drawn. The premise is that in a normal radiograph the superior-lateral dome of the talus lies medial to the handle of TFL, and in ankle with talar shift the dome of the talus would cross this line laterally. In two district hospitals 100 radiographs were observed by 4 observers in 67 males and 33 females with mean age of 49 (15–82) years. The TFL confirmed talar shift with sensitivity of 99.2 % showing talarshift and inferior tibio-fibular ankle diastasis. We conclude that in ankle anterio-posterior view it is possible to comment on the talar shift and diastasis of the ankle joint, even if proper ankle mortise views were not available

The diagnosis of Lisfranc ligament disruption is notoriously difficult. Radiographs and MRI scans are often ambiguous therefore a stress-test examination under anaesthesia is commonly required. Two midfoot stress-tests are in current practice, namely the varus first ray stress-test and the pronation abduction test. The optimal type of stress-test is not however evaluated in the literature. We hypothesised that after the loss of the main plantar stabiliser (the Lisfranc ligament) the patient would demonstrate dorsal instability, not the classic 1. st. /2. nd. metatarsal diastasis commonly described. We therefore devised a push-up test (placement of a force under the 2. nd. metatarsal in an attempt to elevate the base away from the middle cuneiform on the lateral radiograph). We aimed to initially test our hypothesis on a cadaveric model. Twelve fresh frozen cadaveric specimens without previous foot injury were used. The 2. nd. tarsometatarsal joint was exposed and the Lisfranc ligament and dorsal capsule were incised. An image intensifier was positioned and standard anteroposterior (AP) and lateral views were obtained. Two previously reported AP stress-tests (varus first ray stress test, pronation abduction test) and the novel test under investigation (‘Lisfranc Push-Up’ test) were duly performed. Images were obtained once the investigator felt the appropriate views were achieved. All twelve of the Lisfranc Push-Up tests showed dorsal subluxation of the 2. nd. metatarsal on the middle cuneiform of greater than 2mm on the lateral radiograph. No diastasis of the 1. st. /2. nd. metatarsals was seen in any of the specimens on the AP radiograph for either of the other two stress-tests. The authors have described a novel way of demonstrating the dorsal instability associated with the ligamentous Lisfranc injury. Our results support the Lisfranc Push-Up test as a reproducible and sensitive method for assessing ligamentous Lisfranc injuries. In our cadaveric model the previously described stress-tests do not work

Introduction:. Fibular malreduction is a common and important cause of pain after surgical fixation following a syndesmosis injury, but it is unclear which components of malreduction correspond to clinical outcome. Plain radiographs have been shown to be unreliable at measuring malreduction when compared to CT scans. A number of published methods for measuring fibular position rely on finding the axis of the fibula. Elgafy demonstrated that fibular morphology varies greatly, and some studies have demonstrated difficulty finding the fibular axis. Methods:. We developed a new method of measuring the distal fibular position on CT images. We used CT studies in 16 normal subjects. Two assessors independently measured the ankle syndesmosis using the Davidovitch method, and our new protocol for fibular AP position, diastasis and fibular length. Results:. We demonstrated that after statistical analysis (Pearson Product Moment Correlation) our method showed improved inter-observer reliability (r = 0.99 and 0.95 vs 0.59 and 0.78 respectively) for diastasis and AP translation, and improved intra-observer reliability (r = 0.99 and 0.99 vs 0.91 and 0.97 respectively). We found inter and intra observer reliability of 0.80 and 0.91 respectively for fibular length, but were unable to find a novel, accurate method for measuring fibular rotation. Conclusions:. Our method is a new, simple, accurate and reproducible system for measuring the ankle syndesmosis. We believe that this method could be used to assess fibular reduction after obtaining CT images of the uninjured side for comparison

Tunning fork lines (TFL) were drawn on ankle anterior-posterior radiograph to assess the talar shift. A 3-D ankle joint reconstruction was prepared by mapping normal ankle joint using auto CAD in 1997. Tunning fork lines were drawn using normal anatomical landmarks on saggital, coronal and transverse planes. The ankle joint anatomical relationship with talus was studied in various rotation simulating radiographic anterior-posterior views and talar shift was studied. Between 2006 and 2012 on antero-posterior view of ankle radiographs and PACS, ‘Tunning Fork Lines’ (TFL) were drawn. The superior two vertical lines of the TFL were drawn above the ankle joint perpendicular to the distal tibial articular surface. First line tangent to anterior lip of the inferior tibio-fibular joint and second line tangent to the posterior lip of the inferior tibio-fibular joint parallel to each other. The horizontal third line was drawn parallel to distal tibial articular surface perpendicular to first two lines connecting them. The fourth line (handle of the tunning fork) was drawn vertically below the ankle joint midway between the first two lines perpendicular to the third line. In a normal radiograph the superior-lateral dome of the talus lies medial to the handle of TFL, and in ankle with talar shift the dome of the talus crosses this line laterally. In two district hospitals 100 radiographs were observed by 4 observers in 67 males and 33 females with mean age of 49 (15–82) years. The TFL confirmed talar shift with sensitivity of 99.2 % showing talarshift and inferior tibio-fibular ankle diastasis. We conclude that in ankle anterio-posterior view it is possible to comment on the talar shift and diastasis of the ankle joint if proper ankle mortise view is not available

Introduction. Haemodynamically compromised patients with biomechanically unstable pelvic fractures need reduction of the pelvic volume to effect tamponade of bleeding bone and vessels. Knee binding, to help achieve this, is advocated in standard Advanced Trauma and Life Support teaching but is rarely used. There are no reports in the literature as to the benefits derived from this simple manoeuvre. The aim of this study was to investigate whether there was an effect on symphysis pubis closure by binding the knees together and to quantify this. Methods. 13 consecutive patients who underwent open reduction and internal fixation of pubic symphysis diastasis +/− sacroiliac joint fixation were recruited prospectively. These patients were transferred from peripheral hospitals to this National tertiary referral level 1 trauma centre for definitive pelvic fracture management. All patients had sustained Antero-Posterior Compression (APC) type pelvic injuries. In theatre, a centred antero-posterior (AP) radiograph was taken without any form of binding on the pelvis. A second AP radiograph was then taken with the knees and ankles held together with the hips internally rotated. A third, final AP radiograph was taken post fixation. Measurements of symphysis pubis widening were made of the digital images taken in theatre. Results. The study population included 11 men and 2 women. The mean age was 46. The average percentage closure of symphysis following knee binding in relation to the final reduced symphysis, post fixation was 69%. Conclusion. Our impression is that this manoeuvre is rarely employed on patients with these types of injury. This is the first study to quantify the effects of this simple manoeuvre. Emergency measures to reduce the pelvic volume and thus limit pelvic haemorrhage are well recognised. We have shown that this simple measure is a useful adjunct and that it has a measurable effect on reducing pubic diastasis

Introduction. The assessment of the accuracy of reduction of the ankle syndesmosis has traditionally been made using plain radiographic measurements. Recent studies have shown that computerized tomography (CT) scan is more sensitive than radiographs in detecting diastasis. The ethos has now therefore shifted towards CT scan assessment of the syndesmosis. There is however no validated method to scan the syndesmosis and measure it on the CT scans. This exposes the patient to significant radiation risk and also to anxiety from inappropriate interpretation from these scans. The objectives of this research project are to investigate the current practice of CT scanning the syndesmosis at a University Hospital and to devise a new CT protocol to reduce radiation exposure to patients and to assist surgeons in interpreting the observations. Methods. Research Ethics Committee approval was obtained. Current practice was evaluated. A new 5 cut CT protocol was devised. Starting at the level of the distal tibial plafond, 5 cuts were made proximally 0.5 cm apart. Accuracy of the syndesmosis reduction was assessed just above the distal tibial plafond. Both the injured and the normal sides were scanned 12 weeks post surgery. The normal side served as a control. Results. Current practice revealed that patients had on an average 620 cuts CT scan with radiation exposure of 0.2 mSv. 25 patients were prospectively recruited for the new 5 cut CT protocol. The radiation exposure with the new protocol was only 0.002 mSv. Comparison with the normal side revealed that 5 (20%) of syndesmosis had residual diastasis. The only difficulty with the new protocol was getting both the ankle joint lines at the same level for the first CT cut. Discussion and Conclusion. Our CT scan protocol has insignificant radiation risk, even lower than a single chest radiograph. Comparing the measurements between the fractured and the normal sides provides an accurate assessment of the reduction of the syndesmosis. Significance of the measurements on the CT scan will be correlated with functional scores