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

The June 2024 Trauma Roundup. 360. looks at: Skin antisepsis before surgical fixation of limb fractures; Comparative analysis of intramedullary nail versus plate fixation for fibula fracture in supination external rotation type IV ankle injury; Early weightbearing versus late weightbearing after intramedullary nailing for distal femoral fracture (AO/OTA 33) in elderly patients: a multicentre propensity-matched study; Long-term outcomes with spinal versus general anaesthesia for hip fracture surgery; Operative versus nonoperative management of unstable medial malleolus fractures: a randomized clinical trial; Impact of smoking status on fracture-related infection characteristics and outcomes; Reassessing empirical antimicrobial choices in fracture-related infections; Development and validation of the Nottingham Trauma Frailty Index (NTFI) for older trauma patients

Background. Supination-external rotation (SER) injuries make up 80% of all ankle fractures. SER stage 2 injuries (AITFL and Weber B) are considered stable. SER stage 3 injury includes disruption of the posterior malleolus (or PITFL). In SER stage 4 there is either medial malleolus fracture or deltoid injury too. SER 4 injuries have been considered unstable, requiring surgery. The deltoid ligament is a key component of ankle stability, but clinical tests to assess deltoid injury have low specificity. This study specifically investigates the role of the components of the deep deltoid ligament in SER ankle fractures. Aim. To investigate the effect of deep deltoid ligament injury on SER ankle fracture stability. Methods. Four matched pairs (8 specimens) were tested using a standardised protocol. Specimens were sequentially tested for stability when axially loaded with a custom rig with up to 750N. Specimens were tested with: ankle intact; lateral injury (AITFL and Weber B); additional posterior injury (PITFL); additional anterior deep deltoid; additional posterior deep deltoid; lateral side ORIF. Clinical photographs and radiographs were recorded. In addition, dynamic stress radiographs were performed after sectioning the deep deltoid and then after fracture fixation to assess tilt of the talus in eversion. Results. All specimens with an intact posterior deep deltoid ligament were stable when loaded and showed no talar tilt on dynamic assessment. Once the posterior deep deltoid ligament was sectioned there was instability in all specimens. Surgical stabilisation of the lateral side prevented talar shift but not talar tilt. Conclusion. If the posterior deep deltoid ligament is intact SER fractures may be managed without surgery in a plantigrade cast. Without immobilisation the talus may tilt, risking deltoid incompetence

The April 2024 Foot & Ankle Roundup³⁶⁰ looks at: Safety of arthroscopy combined with radial extracorporeal shockwave therapy for osteochondritis of the talus; Bipolar allograft transplantation of the ankle; Identifying risk factors for osteonecrosis after talar fracture; Balancing act: immediate versus delayed weightbearing in ankle fracture recovery; Levelling the field: proximal supination osteotomy’s efficacy in severe and super-severe hallux valgus; Restoring balance: how adjusting the tibiotalar joint line influences movement after ankle surgery.

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 ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes. Methods. Data on a consecutive group of elite athletes who underwent isolated reconstruction of the anterior inferior tibiofibular ligament using the InternalBrace were collected prospectively. Our patient group consisted of 19 elite male athletes with a mean age of 24.5 years (17 to 52). Isolated injuries were seen in 12 patients while associated injuries were found in seven patients (fibular fracture, medial malleolus fracture, anterior talofibular ligament rupture, and posterior malleolus fracture). All patients had a minimum follow-up period of 17 months (mean 27 months (17 to 35)). Results. All patients returned to their pre-injury level of sports activities. One patient developed a delayed union of the medial malleolus. The mean return to play was 62 days (49 to 84) for isolated injuries, while the patients with concomitant injuries returned to play in a mean of 104 days (56 to 196). The AOFAS score returned to 100 postoperatively in all patients. Knee-to-wall measurements were the same as the contralateral side in 18 patients, while one patient lacked 2 cm compared to the contralateral side. Conclusion. This study suggests the use of the InternalBrace in the management of unstable syndesmotic injuries offers an alternative method of stabilization, with good short-term results, including early return to sports in elite athletes. Cite this article: Bone Joint J 2022;104-B(1):68–75

Introduction and Objective. Postoperative management regimes vary following open reduction and internal fixation of unstable ankle fractures. There is an evolving understanding that poorer outcomes could be associated with non-weight bearing protocols and immobilisation. Traditional non-weight bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The aim of this systematic review and meta-analysis is to compare the complication rate and functional outcomes of early weight-bearing (EWB) versus late weight-bearing (LWB) following open reduction and internal fixation of ankle fractures. Materials and Methods. We performed a systematic review with a meta-analysis of controlled trials and comparative cohort studies. MEDLINE (via PubMed), Embase and the Cochrane Library electronic databases were searched inclusive of all date up to the search time. We included all studies that investigated the effect of weight-bearing following adults ankle fracture fixation by any means. All ankle fracture types, including isolated lateral malleolus fractures, isolated medial malleolus fractures, bi-malleolar fractures, tri-malleolar fractures and Syndesmosis injuries, were included. All weight-bearing protocols were considered in this review, i.e. immediate weight-bearing (IMW) within 24 hours of surgery, early weight-bearing (EWB) within three weeks of surgery, non-weight-bearing for 4 to 6 weeks from the surgery date (or late weight-bearing LWB). Studies that investigated mobilisation but not weight-bearing, non-English language publications and tibial Plafond fractures were excluded from this systematic review. We assessed the risk of bias using ROB 2 tools for randomised controlled trials and ROBINS-1 for cohort studies. Data extraction was performed using Covidence online software and meta-analysis by using RevMan 5.3. Results. After full-text review, fourteen studies (871 patients with a mean age ranged from 35 to 57 years) were deemed eligible for this systematic review; ten randomised controlled trials and four comparative cohort studies. Most of the included studies were rated as having some concern with regard to the risk of bias. There is no important difference in the infection rate between protected EWB and LWB groups (696 patients in 12 studies). The risk ratio (RR) is 1.30, [95% CI 0.74 to 2.30], I. 2. = 0%, P = 0.36). Other complications were rare. The Olerud-Molander Ankle Score (OMAS) was the widely used patient-reported outcome measure after ankle fracture fixation among the studies. The result of the six weeks OMAS analysis (three RCTs) was markedly in favour of the early weight-bearing group (MD = 10.08 [95% CI 5.13 to 15.02], I. 2. = 0%P = <0.0001). Conclusions. The risk of postoperative complications is an essential factor when considering EWB. We found that the overall incidence of surgical site infection was 6%. When comparing the two groups, the incidence was 5.2% and 6.8% for the LWB and EWB groups. This difference is not clinically important. On the other hand, significantly better early functional outcome scores were detected in the EWB group. These results are not without limitations. Protected early weight-bearing following open reduction and internal fixation of ankle fractures is potentially safe and improve short-term functional outcome. Further good-quality randomised controlled trials would be needed before we could draw a more precise conclusion

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.

Aims

This study is a prospective, non-randomized trial for the treatment of fractures of the medial malleolus using lean, bioabsorbable, rare-earth element (REE)-free, magnesium (Mg)-based biodegradable screws in the adult skeleton.

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

Introduction. We performed a longitudinal outcome study involving the operative management of ankle fractures at two university teaching hospitals. This was a retrospective review of the quality of reduction and a prospective study into the functional outcome. Methods. All patients undergoing open reduction internal fixation of the ankle between November 2006 and November 2007 at one centre, and January to December 2009 at the other were included. Adequacy of reduction was assessed on the initial post-operative radiographs using Pettrone's criterion. The post-operative functional outcome was recorded using the Lower Extremity Functional Scale (LEFS), completed by postal or telephone follow-up at 64 months post injury (60–74 months). Results. There were 261 patients in the cohort, with a mean age of 47 years (17–91). Weber B fractures were sustained in 193 patients compared to 68 Weber C fractures. The medial malleolus was fractured in 43 cases, and a large posterior malleolar fragment (>20%) was found in 13 cases. Malreduction of the Weber B cohort was identified in 61 ankles (31%): Malreduction of the Weber C cohort was identified in 25 cases (37%): At time of follow-up 26 patients were not traceable or had died. Of the surviving 235 patients, 139 responded to the LEFS questionnaire (60%). The mean LEFS was 58 (out of 80) in the Weber B cohort and 61 in the Weber C cohort. Significantly lower LEFS were found in patients who had a malreduction in 2 or more criteria. Conclusion. Our study shows that there is high incidence of malreduction in the operative treatment of ankle fractures which leads to a significantly poorer functional outcome. We strongly recommend that adequate care and supervision are used in theatre together with post-operative independent review of intra-operative fluoroscopy images

Most of current literatures advise on thromboprophylaxis with injectable LMWH for trauma patients. Injectable anticoagulants have got inherent problems of pain, bruising and difficulty in administering the drug, which leads to low compliance. Clexane is derived from a pig's intestinal mucosa, hence could be objectionable to certain proportion of patients because of their religious beliefs. Oral anticoagulants have been used as thromboprophylactic agents in hip and knee arthroplasty. However there is not enough literature supporting their use as thromboprophylactic agent in ambulatory trauma patients with ankle fracture being managed non-operatively as out-patient. This study looks into the efficacy of oral anticoagulant in preventing VTE in ambulatory trauma patients requiring temporary lower limb immobilisation for management of ankle fracture. The end point of this study was symptomatic deep vein thrombosis (either proximal or distal) and pulmonary embolism. Routine assessment with a VTE assessment risk proforma for all patients with temporary lower limb immobilisation following lower limb injury requiring plaster cast is done in the fracture clinic at this university hospital. These patients are categorised as low or high risk for a venous thromboembolic event depending on their risk factor and accordingly started on prophylactic dose of oral anticoagulant (Rivaroxaban - Factor Xa inhibitor). Before the therapy is started these patients have a routing blood check, which includes a full blood count and urea and electrolyte. Therapy is continued for the duration of immobilisation. Bleeding risk assessment is done using a proforma based on NICE guideline CG92. If there is any concern specialist haematologist advice is sought. A total of 200 consecutive patients who presented to the fracture clinic with ankle fracture, which was managed in plaster cast non-operatively, were included in this study. They were followed up for three months following injury. This was done by checking these patients’ radiology report including ultrasound and CT pulmonary scan (CTPA) test on hospital's electronic system. Fracture of the lateral malleolus which include Weber-A, Weber-B and Weber-C fractures were included in the study. Also included were bimalleolar fractures and isolated medial malleolus fractures. Complex pilon fractures, polytrauma and paediatric patients were excluded from the study. Only one case of plaster associated isolated distal deep vein (soleal vein) thrombosis was reported in this patient subgroup. There was no incidence of proximal deep vein thrombosis or pulmonary embolism. No significant bleeding event was reported. Injectable low molecular weight heparin (LMWH) rather than oral anticoagulant has been recommended by most of the studies and guidelines as main thromboprophylactic agent for lower limb trauma patients

The AO Foundation advocates the use of partially threaded lag screws in the fixation of fractures of the medial malleolus. However, their threads often bypass the radiodense physeal scar of the distal tibia, possibly failing to obtain more secure purchase and better compression of the fracture.

We therefore hypothesised that the partially threaded screws commonly used to fix a medial malleolar fracture often provide suboptimal compression as a result of bypassing the physeal scar, and proposed that better compression of the fracture may be achieved with shorter partially threaded screws or fully threaded screws whose threads engage the physeal scar.

We analysed compression at the fracture site in human cadaver medial malleoli treated with either 30 mm or 45 mm long partially threaded screws or 45 mm fully threaded screws. The median compression at the fracture site achieved with 30 mm partially threaded screws (0.95 kg/cm² (interquartile range (IQR) 0.8 to 1.2) and 45 mm fully threaded screws (1.0 kg/cm² (IQR 0.7 to 2.8)) was significantly higher than that achieved with 45 mm partially threaded screws (0.6 kg/cm² (IQR 0.2 to 0.9)) (p = 0.04 and p < 0.001, respectively). The fully threaded screws and the 30mm partially threaded screws were seen to engage the physeal scar under an image intensifier in each case.

The results support the use of 30 mm partially threaded or 45 mm fully threaded screws that engage the physeal scar rather than longer partially threaded screws that do not. A 45 mm fully threaded screw may in practice offer additional benefit over 30 mm partially threaded screws in increasing the thread count in the denser paraphyseal region.

Cite this article: Bone Joint J 2013;95-B:1662–6.

Introduction. Among patients with ankle osteoarthritis (OA) a post-traumatic origin is much more frequent than among those with knee or hip OA. However, long-term studies evaluating risk factors for the development of OA after ankle fractures are lacking. Methods. Retrospective cohort study including consecutive patients operated at our institution between 1/1988 and 12/1997 for malleolar fractures treated with open-reduction and internal fixation (ORIF). Ankle OA was independently assessed by two reviewers on standardized radiographs using the Kellgren and Lawrence (K&L) scale. Multivariate logistic regression analysis was performed to determine predictors for OA. Results. 374 patients (56% men) underwent ankle surgery during the study period. 9% had a Weber A, 58% a Weber B and 33% a Weber C fracture. Mean age at operation was 42.9 years. 12–22 years after surgery, 47 patients had died, 126 were lost to follow-up, and 99 did not respond or refused to participate. 102 patients were available at follow-up (similar age, gender, BMI and type of fracture than those not seen). Mean follow up was 17.3 years. Advanced OA (K&L 3–4) was present in 37 patients (36.3%). Significant risk factors for advanced OA were: fracture type (Weber C 53% vs. Weber B 31% vs. Weber A 0%, p = 0.006), presence of medial malleolus fracture, fracture-dislocation, increasing BMI, older age, and longer follow-up time. Conclusion. Advanced ankle osteoarthritis is frequent (36%) 12–22 years after a malleolar fracture, especially after Weber C fractures, medial malleolus fractures or fracture-dislocation. Obese and older patients are at increased risk

Background. Postoperative pain following (Mobility TM) ankle arthroplasty (AA) is recognised problem. This study aimed to determine pattern of postoperative pain following Ankle arthroplasty (AA). Materials and Methods. In prospective observational study 135 patients who had (AA) and follow-up of 12–36 months were included. AOFAS ankle score, patients' satisfaction, SF36 and diagrammatic mapping of postoperative pain among other parameters were collected preoperatively and postoperatively at 3 months, 6 months and the annually. Patients with AOFAS of < 50 with postoperative ankle pain were examined in details. Results. From total of 135 of patients with follow-up of 12 months, (12.5%)17 patients have low AOFAS score and ankle pain, 11(12.5%) of 85 patients with 2 year follow-up and (10.6%),5 of 47 patients with 3 year follow-up. Most of patients with low AOFAS score during first year have improved but 3 patients. Different group patients developed ankle pain during the second and third year. 3 patients of 5, in year 3 follow-up have medial side ankle pain and 2 lateral; similarly there is more medial sided pain during year 2 review (7/11). There is more medial sided pain noticed during first postoperative year as well. Lateral pain seems to relate with subtalar joints problems. Medial side pain is less understandable, it might be due to tension in medial ankle ligaments. Our study showed improvement in AOFAS score and pain relief associated with medial ligaments release or medial malleolus fracture. Conclusion. There are 10–13 % of low AOFAS scores following Ankle Arthroplasty with ankle pain. There are emerging evidences explaining postoperative ankle pain. Further studies are required in this field

Conventionally, medial malleolus fractures are treated surgically with anatomical reduction and internal fixation using screws. There seems to be no consensus, backed by scientific study on the optimal screw characteristics in the literature. We retrospectively examined case notes and radiographs of 48 consecutive patients taken from our trauma database (21 male, 27 female) with an average age of 50 years (range 16-85) who had undergone medial malleolus fracture fixation with screws at the Royal Free Hospital, London between January 2009 and June 2010. The most commonly used screw was the AO 4.0 mm diameter cancellous partially-threaded screw in 40, 45 and 50 mm lengths (40 mm n = 28, 45 mm n = 26, 50 mm n = 23) with the threads passing beyond the physeal scar in all cases. Incomplete reduction defined as > 1mm fracture displacement was observed on post-operative x-rays in 12 out of 48 cases (25%), all of which relied on partially-threaded screw fixation. In 5 cases where AO 4.0 mm diameter fully-threaded screws engaging the physeal scar had been used, no loss of reduction was observed. This unusual, occasional use of fully-threaded screws prompted us to investigate further using a porcine model and adapted pedo-barographic transducer. We compared pressures generated within the fracture site using AO 4.0 mm partially-threaded cannulated screws, 4.0 mm partially-threaded cancellous screws and 4.0 mm fully-threaded cancellous screws. Fully-threaded cancellous 4.0 mm diameter screws generated almost 3 times the compression of a partially-threaded cancellous screw with superior stability at the fracture. Partially-threaded screws quickly lost purchase, compression and stability particularly when they were cannulated. We also observed that screw thread purchase seemed enhanced in the physeal region. We conclude that fully-threaded cancellous 4.0 mm AO screws are superior to longer partially-threaded screws and that use of cannulated 4.0 mm partially-threaded screws should be avoided in fixation of medial malleolus fractures

Purpose. The aim of this prospective study was to determine the usefulness of a gravity stress view in detecting instability in isolated Weber B fractures of the fibula. Materials and methods. We used a standard protocol for patient selection, exclusion, surgery/conservative management and follow-up. Open fractures, fracture dislocations, those with medial/posterior malleolus fractures and those with preliminary X-rays showing a talar shift/tilt were excluded. If the medial clear space increased beyond 4mm on stress radiographs, surgical reduction and fixation of the lateral malleolus was performed. If this remained 4mm or less conservative treatment was undertaken. We followed these patients at 2, 4, 6 and 12 weekly intervals. Results. We recruited 18 patients with isolated Weber B fractures. In 7 patients the medial clear space increased from 4mm to an average of 6.29 mm (Range 5-7mm). 6 of these 7 patients were operated. The medial clear space remained 4mm or less in the remaining 11 patients and were therefore managed conservatively. No complications were noted in either the surgical or the non-surgical group. None of the conservatively managed fractures showed radiological features of instability on follow up. All the 17 patients who were followed up in our hospital had excellent final AOFAS Scores. Conclusion. We conclude that gravity stress views are useful in determining the stability of Weber B fractures of the ankle

Aim: To assess whether stable undisplaced ankle fractures treated conservatively with a below knee non weight bearing cast ever displace. Methods: Retrospective case notes analysis was performed. Between August 2007 and August 2009, one hundred and twenty one patients sustained a stable undisplaced ankle fracture which was treated conservatively. Their age range was from 16 to 86 years. Male to female ratio was 74:47. The mean number of clinic follow ups was 3.7. These patients were classified according to the Danis-Weber Classification for analysis. Thirty (25%) patients had Weber A1 fractures, seventy two (60%) had Weber B1 fractures, five patients (4%) had Weber B2 fractures, three patients (2%) had Weber C1 fractures, ten patients (8%) had isolated medial malleolus fracture and one patient suffered an isolated posterior malleolus fracture. Results: An average of 4.7 x-rays were performed on each patient from the time of diagnosis to discharge from clinic. None of these fractures displaced on follow up x-rays. Conclusion: Stable undisplaced ankle fractures treated conservatively with a below knee non weight bearing cast do not displace. Hence these patients do not require to be followed up frequently with serial x-rays as they may be exposed to unnecessary harmful radiation and follow up appointments thereby saving time, money and resources

Introduction: Mac Farland fracture is a joint fracture of the ankle in children, which involves the medial malleolus (Salter-Harris type III or IV) and is frequently associated with a fracture of the distal fibula. These injuries have a major risk of resulting in a medial epiphysiodesis bridge which, in turn, can lead to a varus deformity. As of today, recommended treatment for displacements wider than 2mm is open reduction with screw fixation. The aim of this study is to evaluate functional and radiological results of a new less invasive surgical procedure. Materials and Methods: We retrospectively analyzed a case series of patients who suffered from a Mac Farland fracture and underwent percutaneous screw fixation with arthrographic control. Data collected for each child included age at diagnosis, gender, mechanism and side of injury, radiological Salter-Harris classification of medial and lateral malleolus fracture, size of the fracture line gap before and after treatment, and duration of cast immobilization. Results are given according to the classification by Gleizes (2000), based on clinical and radiological criteria: good, fair, and poor. Results: There were twelve patients, five girls and seven boys, with a mean age of twelve years and six months (range: 10–15). Average follow-up was eighteen months (range: 9–57). Medial malleolus fracture was Salter-Harris type III in seven patients and type IV in five. The mean preoperative fracture line gap was 2.7mm (range: 2–4). All the patients underwent closed reduction and ankle arthrography to check for anatomical reposition. The fracture was then percutaneously fixed with two screws in nine patients and one screw in three. Duration of cast immobilization after surgery was forty-five days in average. At the time of last follow-up the functional and radiological results were good for all the patients according to Gleizes’ classification. Conclusion: Closed reduction combined to ankle arthrography followed by percutaneous osteosynthesis is, in our opinion, an interesting less invasive surgical alternative to classic open reduction and internal fixation for displaced Mac Farland fractures