Aims

Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets.

Aims

Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis.

Aims

The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

Aims

The morphology of medial malleolar fracture is highly variable and difficult to characterize without 3D reconstruction. There is also no universally accepeted classification system. Thus, we aimed to characterize fracture patterns of the medial malleolus and propose a classification scheme based on 3D CT reconstruction.

Abstract

The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants.

Cite this article: Bone Joint J 2019;101-B:512–521.

Aims

Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent.

Aims

The purpose of this study was to compare the clinical and radiographic outcomes of total ankle arthroplasty (TAA) in patients with pre-operatively moderate and severe arthritic varus ankles to those achieved for patients with neutral ankles.

Stable fractures of the ankle can be safely treated non-operatively. It is also gradually being recognised that the integrity of the ‘medial column’ is essential for the stability of the fracture. It is generally thought that bi- and tri-malleolar fractures are unstable, as are pronation external rotation injuries resulting in an isolated high fibular fracture (Weber type-C), where the deltoid ligament is damaged or the medial malleolus fractured. However, how best to identify unstable, isolated, trans-syndesmotic Weber type-B supination external rotation (SER) fractures of the lateral malleolus remains controversial.

We provide a rationale as to how to classify SER distal fibular fractures using weight-bearing radiographs, and how this can help guide the management of these common injuries.

Cite this article: Bone Joint J 2017;99-B:851–5.

We prospectively assessed the diagnostic accuracy of the gravity stress test and clinical findings to evaluate the stability of the ankle mortise in patients with supination–external rotation-type fractures of the lateral malleolus without widening of the medial clear space. The cohort included 79 patients with a mean age of 44 years (16 to 82). Two surgeons assessed medial tenderness, swelling and ecchymosis and performed the external rotation (ER) stress test (a reference standard). A diagnostic radiographer performed the gravity stress test.

For the gravity stress test, the positive likelihood ratio (LR) was 5.80 with a 95% confidence interval (CI) of 2.75 to 12.27, and the negative LR was 0.15 (95% CI 0.07 to 0.35), suggesting a moderate change from the pre-test probability. Medial tenderness, both alone and in combination with swelling and/or ecchymosis, indicated a small change (positive LR, 2.74 to 3.25; negative LR, 0.38 to 0.47), whereas swelling and ecchymosis indicated only minimal changes (positive LR, 1.41 to 1.65; negative LR, 0.38 to 0.47).

In conclusion, when gravity stress test results are in agreement with clinical findings, the result is likely to predict stability of the ankle mortise with an accuracy equivalent to ER stress test results. When clinical examination suggests a medial-side injury, however, the gravity stress test may give a false negative result.

Cite this article: Bone Joint J 2015; 97-B:1126–31.

Introduction:. The aim of this study was to identify the rate of complications of total ankle replacement in a single Centre to help with informed patient consent. Methods:. Between 2008 and 2012, 202 total ankle replacements (TARs) were performed by 4 surgeons at our Institute. Data was collected on all patients; demographics, arthritic disease, pre-operative deformity, prosthesis and all early and late complications. Results:. 4 surgeons (A, B, C, D) performed 63, 55, 48 and 36 TARs (178 De Puy Mobility and 24 Corin Zenith). 130 patients had primary osteoarthrosis, 35 had rheumatoid and 36 had post traumatic osteoarthrosis. There were no differences in patient demographics for each surgeon. There were 3 deep infections (A, B, C, D: 1,0,2,0). There were 18 medial malleolar fractures (8 intra-operative [4,1,1,2], 3 early (< 3 months) [1,1,0,1] and 7 late (> 3 months) [2,2,2,1]). There were 2 lateral malleolar fractures, both intra-operative (0,0,1,1). There were 15 patients who developed superficial wound infections, which resolved fully with oral antibiotics (4,3,4,4). A further 7 patients had a delay to wound healing (wound not fully healed at 3 months) (4,0,2,1); 2 of these developed deep infection and failed. 22 patients had persistent medial gutter pain (9,4,5,4); all had undergone Mobility TAR. 4 patients developed recurrent edge loading and have had to be revised (4 converted to TTC fusion) (2,0,2,0). We report complications in 32% of patients. Overall 9 TARs failed and underwent revision to fusion (2,2,5,0). Conclusion:. We report an overall complication rate of 32% following TARs, however most are minor and don't affect clinical outcome. We had a 1.5% deep infection rate. Complication rates were comparable between 4 surgeons. There was a difference in medial gutter pain rate between implants (13% v 0% Mobility to Zenith). This data provides detailed complication rates for informed consent

Introduction:. Isolated Weber B lateral malleolus fractures heal uneventfully, but concern that late subluxation may occur due to unrecognised medial ligament tearing, despite an intact mortice on initial radiographs, often results in overtreatment. The aim of this study was to determine the incidence of late talar shift with nonoperative management in a cohort of patients with no initial talar shift, and also record functional outcomes at 16–28 months following injury. Methods:. This was a retrospective review of 129 patients with Weber B lateral malleolar fractures initially referred to the fracture clinic between October 2011 and October 2012. Eight had obvious talar shift and therefore underwent surgery, with the remaining 121 treated in plaster (n=41), a Velcro boot (n=70) or bandage (n=10). No stress x-rays or MRI scans were performed. Weight-bearing was permitted as pain allowed. Radiographs taken on discharge from the clinic were reviewed to assess talar shift. Functional outcomes assessment was carried out using Manchester Oxford Foot Questionnaire and Olerud-Molander score. Results:. None of the 121 patients had talar shift initially; 21 patients where medial injury was strongly suspected were closely followed and had check x-rays more often (average 2.9 appointments per patient) than the other groups. No patients had talar shift in any of the subsequent x-rays and therefore none underwent delayed internal fixation. The mean MOXFQ and Olerud-Molander scores were 27 and 78 respectively in 57 patients and the functional outcomes were not influenced by type of immobilisation or suspected medial injury. Conclusion:. Our observation is that the risk of late talar shift is likely to be low in patients where initial x-rays had showed no talar displacement. It may be unnecessary to perform additional tests/imaging to establish the integrity of the medial ligament as satisfactory functional results are routinely observed

Assessment of stability in ankle fractures is key in deciding the most appropriate mode of treatment. Stress radiographs have been suggested as a potential method for assessing ankle stability in patients with apparently isolated lateral malleolar fractures. Whilst stress radiographs have been found to be both sensitive and specific in cadaveric experiments, recent clinical studies have suggested that a widened medial clear space (MCS) on stress radiographs may not equate to a functionally unstable ankle. We aimed to assess whether patients with an apparently isolated lateral malleolar fracture on presentation but with a positive gravity stress radiograph (GSR) could be successfully managed non-operatively. A prospective study of all patients with lateral malleolar fractures presenting to our orthopaedic trauma department was undertaken. Patients with an oblique distal fibular fracture pattern and no obvious MCS widening on routine radiographs underwent a GSR. Measurements of the radiographic MCS and superior clear space (SCS) were made and compared with published criteria. 155 patients were included in the study and treated non-operatively fully weight bearing in either a cast or removable boot. Following fracture union all patients had both anatomical alignment of the ankle mortise and good or excellent function. The MCS of 79% of these patients was found to be greater than 4 mm with 19% greater than 6 mm. All of these patients were successfully managed non-operatively. The currently used criteria for measurements on stress radiographs result in high numbers of false positive cases. This may be leading to unnecessary surgery. Further investigation is required in order to identify other clinical or radiographic criteria that may be of use in the assessment of functional ankle stability after fracture

Little is known about the long-term outcome of mobile-bearing total ankle replacement (TAR) in the treatment of end-stage arthritis of the ankle, and in particular for patients with inflammatory joint disease. The aim of this study was to assess the minimum ten-year outcome of TAR in this group of patients.

We prospectively followed 76 patients (93 TARs) who underwent surgery between 1988 and 1999. No patients were lost to follow-up. At latest follow-up at a mean of 14.8 years (10.7 to 22.8), 30 patients (39 TARs) had died and the original TAR remained in situ in 28 patients (31 TARs). The cumulative incidence of failure at 15 years was 20% (95% confidence interval (CI) 11 to 28). The mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot score of the surviving patients at latest follow-up was 80.4 (95% CI 72 to 88). In total, 21 patients (23 TARs) underwent subsequent surgery: three implant exchanges, three bearing exchanges and 17 arthrodeses. Neither design of TAR described in this study, the LCS and the Buechel–Pappas, remains currently available. However, based both on this study and on other reports, we believe that TAR using current mobile-bearing designs for patients with end-stage arthritis of the ankle due to inflammatory joint disease remains justified.

Cite this article: Bone Joint J 2013;95-B:1656–61.

In a retrospective study we compared 32 HINTEGRA total ankle replacements (TARs) and 35 Mobility TARs performed between July 2005 and May 2010, with a minimum follow-up of two years. The mean follow-up for the HINTEGRA group was 53 months (24 to 76) and for the Mobility group was 34 months (24 to 45). All procedures were performed by a single surgeon.

There was no significant difference between the two groups with regard to the mean AOFAS score, visual analogue score for pain or range of movement of the ankle at the latest follow-up. Most radiological measurements did not differ significantly between the two groups. However, the most common grade of heterotopic ossification (HO) was grade 3 in the HINTEGRA group (10 of 13 TARs, 76.9%) and grade 2 in the Mobility group (four of seven TARs, 57.1%) (p = 0.025). Although HO was more frequent in the HINTEGRA group (40.6%) than in the Mobility group (20.0%), this was not statistically significant (p = 0.065).The difference in peri-operative complications between the two groups was not significant, but intra-operative medial malleolar fractures occurred in four (11.4%) in the Mobility group; four (12.5%) in the HINTEGRA group and one TAR (2.9%) in the Mobility group failed (p = 0.185).

Cite this article: Bone Joint J 2013;95-B:1075–82.

It has previously been suggested that among unstable ankle fractures, the presence of a malleolar fracture is associated with a worse outcome than a corresponding ligamentous injury. However, previous studies have included heterogeneous groups of injury. The purpose of this study was to determine whether any specific pattern of bony and/or ligamentous injury among a series of supination-external rotation type IV (SER IV) ankle fractures treated with anatomical fixation was associated with a worse outcome.

We analysed a prospective cohort of 108 SER IV ankle fractures with a follow-up of one year. Pre-operative radiographs and MRIs were undertaken to characterise precisely the pattern of injury. Operative treatment included fixation of all malleolar fractures. Post-operative CT was used to assess reduction. The primary and secondary outcome measures were the Foot and Ankle Outcome Score (FAOS) and the range of movement of the ankle.

There were no clinically relevant differences between the four possible SER IV fracture pattern groups with regard to the FAOS or range of movement. In this population of strictly defined SER IV ankle injuries, the presence of a malleolar fracture was not associated with a significantly worse clinical outcome than its ligamentous injury counterpart. Other factors inherent to the injury and treatment may play a more important role in predicting outcome.

Introduction: Conventional metal ankle plates often require secondary removal due to problems such as discomfort or pain. Biodegradable ankle plates and screws have been developed to avoid the need for hardware removal. However, only limited clinical data exists with these new devices. The aim of this study was to retrospectively followup ankle fracture patients treated with biodegradable ankle plates and screws at the Seinäjoki Central Hospital (Finland), and to evaluate clinical outcome and occurrence of postoperative complications in these patients. Materials and Methods: After ethical committee approval, 57 ankle fracture patients treated with the biodegradable ankle plates and screws (Inion OTPS™, Inion Oy, Tampere, Finland) at the Seinäjoki Central Hospital between March 2004 and September 2006 were invited for a follow-up visit at a private outpatient clinic. Totally 50 patients participated (21 female, 29 male) in the study. There were 36 lateral malleolar fractures (2 with syndesmosis rupture) and 14 bimalleolar fractures (3 with syndesmosis rupture). The average age of the patients was 45 years (SD ± 14, range 18–65) and average weight was 80 kg (SD ± 18, range 45–150). Postoperatively, a cast was applied for 6 weeks. The patients were instructed as follows: First no weight bearing for 2 weeks, then half body weight bearing for 2 weeks, and thereafter gradually towards full weight bearing (with pain restriction). The follow-up included review of each patient’s medical records, evaluation of radiographs (preoperative, postoperative, and the ones taken at the follow-up visit) and fracture reduction classification according to Cedell (anatomic, good, poor), and functional scoring according to Olerud and Molander (0–100). All complications were recorded. In addition, duration of return to work and normal daily activities were asked from each patient. Results: Average follow-up time was 17 months (SD ± 6.2, range 7–36). No perioperative complications occurred. All fractures healed. Fracture alignment was classified as anatomic in 49 patients and good in 1 case. Average Olerud and Molander ankle score was 86 (SD ± 20, range 15–100). Average duration of return to work was 2.8 months (SD ± 1.3, range 1.5–6), and average duration of return to normal daily activities 3.1 months (SD ± 1.3, range 1.5–6). Postoperative complications: 1 delayed wound healing, 3 cases of deep venous thrombosis, and 4 soft tissue reactions. Discussion and Conclusions: According to the results of this retrospective study, biodegradable ankle plates and screws provide comparable fracture healing and functional results as those previously reported after use of conventional metal fixation (Lehtonen et al. 2003). Also postoperative complications and their occurrence rates are similar to those seen with metal

Purpose: Many lateral malleolar fractures in patients with osteoporotic bone are rotationally unstable, requiring fixation stable in torsion with good fatigue properties, but without bulk due to the soft tissue constraints. The purpose of this study was to evaluate the torsional performance of a thin (1.5mm) plate with locked and non-locked constructs in a simulated osteoporotic lateral malleolus fracture. Method: A transverse fracture gap to mimic comminution was created in (15 lb/ft3) density foam. 3 bicortical unlocked screws were used proximal to the fracture in a 5 hole thin (1.5mm) plate for both constructs. Distally, two screws that did not breach the far cortex (12mm) were placed as locked in one group and unlocked in the other. The constructs were loaded in torsion at 1 Hz at 7.5/0.75 in-lbf (0.85/0.08 N-m) of torque. A torsional fatigue failure was defined as either a fracture of the plate, screw pull-out, or construct rotation 10 degrees beyond the maximum initial rotational displacement. Testing was conducted until construct failure or run-out of 300,000 cycles. Results: The thin plate constructs with locked distal screws showed significantly improved fatigue properties (p< 0.00001). None of the locking plate constructs failed prior to the 300,000 cycle end point. In stark contradistinction, all of the non-locked contructs failed at an average cycle count of only 9,541 (range 1,000 – 23,000 cycles). The failure mode for each of the non-locked constructs was pull-out of the distal screws. Conclusion: These results indicate that the use of a thin plate with locking capability provides a significant advantage over non-locked constructs in fatigue performance in areas of poor bone density subjected to torsional loads, such as the lateral malleolus

Advances in implant design and instrumentation have led to total ankle replacement (TAR) becoming an attractive alternative to ankle fusion in selected cases. We present the short-term results for Mobility TAR with clinical and radiological findings. Methods: Prospective study from Dec 2004 to Dec 2007. Single surgeon, anterior approach to the ankle. Patients assessed clinically, radiologically and with pre and postoperative visual analogue (VAS) and American orthopaedic foot and ankle society (AOFAS) hindfoot score. Results: 34 patients, 36 TAR, 2 bilateral. Male 25, female nine. Mean age 66.9 years, range 43 to 89 years. 26 osteoarthritis, four rheumatoid arthritis, four post-traumatic osteoarthritis. Follow up 6 months to 3.5 yrs, mean 22 months. VAS pre-operative mean 8, postoperative mean 1.5. AOFAS score mean pre-operative 30, post-operative mean 85. No deep infections, 3 superficial infections, which settled with antibiotics. No nerve damage. Two medial malleolar fractures. Two lateral malleolar fractures. One talar malposition – one of first six cases, no surgery required outcome not affected. Three unexplained painful TAR. No revisions. 90% patients satisfied and would have operation again. Conclusion: Short-term results for TAR are encouraging. Implants and instrumentation are improving and patients are satisfied with the results. There is a steep learning curve of at least six cases. Surgical skill, technique and careful patient selection are paramount in achieving satisfactory results. With patient demands increasing TAR is a realistic alternative to ankle fusion

We have compared the results at a mean follow-up of 13 years (11 to 14) of two groups of supination-external rotation type-4 fractures of the ankle, in one of which there was a fracture of the medial malleolus and in the other the medial deltoid ligament had been partially or completely ruptured.

Of 66 patients treated operatively between 1993 and 1997, 36 were available for follow-up. Arthroscopy had been performed in all patients pre-operatively to assess the extent of the intra-articular lesions. The American Orthopaedic Foot and Ankle Society hind-foot score was used for clinical evaluation and showed a significant difference in both the total and the functional scores (p < 0.05), but not in those for pain or alignment, in favour of the group with a damaged deltoid ligament (p < 0.05). The only significant difference between the groups on the short-form 36 quality-of-life score was for bodily pain, again in favour of the group with a damaged deltoid ligament. There was no significant difference between the groups in the subjective visual analogue scores or in the modified Kannus radiological score.

Arthroscopically, there was a significant difference with an increased risk of loose bodies in the group with an intact deltoid ligament (p < 0.005), although there was no significant increased risk of deep cartilage lesions in the two groups.

At a mean follow-up of 13 years after operative treatment of a supination-external rotation type-4 ankle fracture patients with partial or complete rupture of the medial deltoid ligament tended to have a better result than those with a medial malleolar fracture.