Aims. To describe outcome reporting variation and trends in non-pharmacological randomized clinical trials (RCTs) of distal tibia and/or ankle fractures. Methods. Five electronic databases and three clinical trial registries were searched (January 2000 to February 2022). Trials including patients with distal tibia and/or ankle fractures without concomitant injuries were included. One reviewer conducted all searches, screened titles and abstracts, assessed eligibility, and completed data extraction; a random 10% subset were independently assessed and extracted by a second reviewer at each stage. All extracted outcomes were mapped to a modified version of the International Classification of Functioning, Disability and Health framework. The quality of outcome reporting (reproducibility) was assessed. Results. Overall, 105 trials (n = 16 to 669 participants) from 27 countries were included. Trials compared surgical interventions (n = 62), post-surgical management options (n = 17), rehabilitative interventions (n = 14), surgical versus non-surgical interventions (n = 6), and pre-surgical management strategies (n = 5). In total, 888 outcome assessments were reported across seven domains: 263 assessed body structure or function (85.7% of trials), 136 activities (68.6% of trials), 34 participation (23.8% of trials), 159 health-related quality of life (61.9% of trials), 247 processes of care (80% of trials), 21 patient experiences (15.2% of trials), and 28 economic impact (8.6% of trials). From these, 337 discrete outcomes were described. Outcome reporting was inconsistent across trials. The quality of reporting varied widely (reproducibility ranged 4.8% patient experience to 100% complications). Conclusion. Substantial heterogeneity in outcome selection, assessment methods, and reporting quality were described. Despite the large number of outcomes, few are reported across multiple trials. Most outcomes are clinically focused, with little attention to the long-term consequences important to patients. Poor reporting quality reduces confidence in data quality, inhibiting data synthesis by which to inform care decisions. Outcome reporting guidance and standardization, which captures the outcomes that matter to multiple stakeholders, are urgently required. Cite this article: Bone Jt Open 2022;3(10):832–840

Aims. We retrospectively report our experience of managing 30 patients with a primary malignant tumour of the distal tibia; 25 were treated by limb salvage surgery and five by amputation. We compared the clinical outcomes of following the use of different methods of reconstruction. Patients and Methods. There were 19 male and 11 female patients. The mean age of the patients was 19 years (6 to 59) and the mean follow-up was 5.1 years (1.25 to 12.58). Massive allograft was used in 11 patients, and autograft was used in 14 patients. The time to union, the survival time of the reconstruction, complication rate, and functional outcomes following the different surgical techniques were compared. The overall patient survival was also recorded. Results. Out of 14 patients treated with an autograft, 12 (86%) achieved union at both the proximal and distal junctions. The time to union at both junctions of the autograft was significantly shorter than in those treated with an allograft (11.1 vs 17.2 months, p = 0.02; 9.5 vs 16.2 months, p = 0.04). The complication rate of allograft reconstruction was 55%. The five patients treated with an amputation did not have a complication. Out of the 25 patients who were treated with limb salvage, three (12%) developed local recurrence and underwent amputation. The mean functional Musculoskeletal Tumor Society (MSTS) score after autograft reconstruction was higher than after allograft reconstruction (81% vs 67%; p = 0.06), and similar to that after amputation (81% vs 82%; p = 0.82). The two- and five-year overall rates of survival were 83% and 70%, respectively. Conclusions. This consecutive case series supports the safety of limb salvage and the effectiveness of biological reconstruction after the resection of a primary tumour of the distal tibia. Autograft might be a preferable option. In some circumstances, below-knee amputation remains a valid option

The ideal form of fixation for displaced, extra-articular fractures of the distal tibia remains controversial. In the UK, open reduction and internal fixation with locking-plates and intramedullary nailing are the two most common forms of treatment. Both techniques provide reliable fixation but both are associated with specific complications. There is little information regarding the functional recovery following either procedure. We performed a randomised pilot trial to determine the functional outcome of 24 adult patients treated with either a locking-plate (n = 12) or an intramedullary nailing (n = 12). At six months, there was an adjusted difference of 13 points in the Disability Rating Index in favour of the intramedullary nail. However, this was not statistically significant in this pilot trial (p = 0.498). A total of seven patients required further surgery in the locking-plate group and one in the intramedullary nail group. This study suggests that there may be clinically relevant, functional differences in patients treated with nail versus locking-plate fixation for fractures of the distal tibia and differences in related complications. Further trials are required to confirm the findings of this pilot investigation

Aims. To report the outcomes of patients with a fracture of the distal tibia who were treated with intramedullary nail versus locking plate in the five years after participating in the Fixation of Distal Tibia fracture (FixDT) trial. Methods. The FixDT trial reported the results for 321 patients randomized to nail or locking plate fixation in the first 12 months after their injury. In this follow-up study, we report the results of 170 of the original participants who agreed to be followed up until five years. Participants reported their Disability Rating Index (DRI) and health-related quality of life (EuroQol five-dimension three-level questionnaire) annually by self-reported questionnaire. Further surgical interventions related to the fracture were also recorded. Results. There was no evidence of a difference in patient-reported disability, health-related quality of life, or the need for further surgery between participants treated with either type of fixation at five years. Considering the combined results for all participants, there was no significant change in DRI scores after the first 12 months of follow-up (difference between 12 and 24 months, 3.3 (95% confidence interval -1.8 to 8.5); p = 0.203), with patients reporting around 20% disability at five years. Conclusion. This study shows that the moderate levels of disability and reduced quality of life reported by participants 12 months after a fracture of the distal tibia persist in the medium term, with little evidence of improvement after the first year. Cite this article: Bone Joint J 2023;105-B(7):795–800

Aims. To systematically review qualitative studies of patients with distal tibia or ankle fracture, and explore their experience of injury and recovery. Methods. We undertook a systematic review of qualitative studies. Five databases were searched from inception to 1 February 2022. All titles and abstracts were screened, and a subset were independently assessed. Methodological quality was appraised using the Critical Appraisal Skills Programme (CASP) checklist. The GRADE-CERQual checklist was used to assign confidence ratings. Thematic synthesis was used to analyze data with the identification of codes which were drawn together to form subthemes and then themes. Results. From 2,682 records, 15 studies were reviewed in full and four included in the review. A total of 72 patients were included across the four studies (47 female; mean age 50 years (17 to 80)). Methodological quality was high for all studies, and the GRADE-CERQual checklist provided confidence that the findings were an adequate representation of patient experience of distal tibia or ankle fracture. A central concept of ‘being the same but different’ conveyed the substantial disruption to patients’ self-identity caused by their injury. Patient experience of ‘being the same but different’ was expressed through three interrelated themes, with seven subthemes: i) being proactive where persistence, doing things differently and keeping busy prevailed; ii) living with change including symptoms, and living differently due to challenges at work and leisure; and iii) striving for normality, adapting while lacking in confidence, and feeling fearful and concerned about the future. Conclusion. Ankle injuries were disruptive, draining, and impacted on patients’ wellbeing. Substantial short- and longer-term challenges were experienced during recovery. Rehabilitation and psychosocial treatment strategies may help to ameliorate these challenges. Patients may benefit from clinicians being cognisant of patient experience when assessing, treating, and discussing expectations and outcomes with patients. Cite this article: Bone Jt Open 2023;4(3):188–197

Aims. The aim of this study was to report the results of three forms of reconstruction for patients with a ditsl tibial bone tumour: an intercalary resection and reconstruction, an osteoarticular reconstruction, and arthrodesis of the ankle. Methods. A total of 73 patients with a median age of 19 years (interquartile range (IQR) 14 to 36) were included in this retrospective, multicentre study. Results. Reconstructions included intercalary resection in 17 patients, osteoarticular reconstruction in 11, and ankle arthrodesis in 45. The median follow-up was 77 months (IQR 35 to 130). Local recurrence occurred in eight patients after a median of 14 months (IQR 9 to 36), without a correlation with adequacy of margins or reconstructive technique. Major complications included fracture of the graft in ten patients, nonunion of the proximal osteotomy in seven, and infection in five. In the osteoarticular group, three of 11 patients developed radiological evidence of severe osteoarthritis, but only one was symptomatic and required conversion to ankle arthrodesis. Functional evaluation showed higher values of the Musculoskeletal Tumour Society (MSTS) and American Orthopaedic Foot and Ankle Society (AOFAS) scores in the intercalary group compared with the others. Conclusion. Preservation of the epiphysis in patients with a distal tibial bone tumour is a safe and effective form of limb-sparing treatment. It requires rigorous preoperative planning after accurate analysis of the imaging. When joint-sparing resection is not indicated, ankle arthrodesis, either isolated tibiotalar or combined tibiotalar and subtalar arthrodesis, should be preferred over osteoarticular reconstruction. Cite this article: Bone Joint J 2020;102-B(11):1567–1573

We have carried out prosthetic reconstruction in six patients with malignant or aggressively benign bone tumours of the distal tibia or fibula. The diagnoses were osteosarcoma in four patients, parosteal osteosarcoma in one and recurrent giant-cell tumour in one. Five tumours were in the distal tibia and one in the distal fibula. The mean duration of follow-up was 5.3 years (2.0 to 7.1). Reconstruction was achieved using custom-made, hinged prostheses which replaced the distal tibia and the ankle. The mean range of ankle movement after operation was 31° and the joints were stable. The average functional score according to the system of the International Society of Limb Salvage was 24.2 and five of the patients had a good outcome. Complications occurred in two with wound infection and talar collapse. All patients were free from neoplastic disease at the latest follow-up. Prosthetic reconstruction may be used for the treatment of malignant tumours of the distal tibia and fibula in selected patients

The purpose of this study was to evaluate and to compare the mechanical stability of external fixation with and without ankle spanning fixation using a foot plate in an in-vitro model of periarticular distal tibia osteotomy/fracture. Ten fresh frozen lower extremities (five pairs) with a simulated distal tibia osteotomy/fracture were stabilised with an Ilizarov hybrid fixator with and without a foot plate. All specimens were loaded using a servohydraulic load frame. Relative interfragmentary motions (vertical and horizontal translations, and rotation) were measured. Statistical analysis was performed as a paired t-test to compare the different frame constructs. A p<0.05 was considered indicative of a significant difference between fixator constructs. The vertical displacement measured at the centre of the distal fragment under load with the foot plate was such that the bone fragments became closer together (-0.83±0.64 mm). Loading of specimens without the foot plate resulted in distraction of the distal fragment (2.57±0.97 mm). The difference was statistically significant (p<0.05). The horizontal displacement of distal fragment with (1.12±0.98 mm) was not significantly different from the motion without (1.19±1.23 mm) a foot plate and was in the anterior direction in both cases. Loading of the construct with the foot plate caused sagittal plane angulation of the fragments with the osteotomy/fracture gap opening anteriorly (-1.15±0.61 deg.). Loading of the construct without a foot plate resulted in sagittal plane angulation of fragments with the gap opening posteriorly (4.49±0.45 deg.). These motion differences were statistically significant (p<0.05). There was not a statistically significant difference between the order of testing the construct with a foot plate and the construct without it (p>0.05). Fixators with ankle spanning using foot plates increase the mechanical stiffness of external fixation of periarticular distal tibia osteotomy/fracture

Introduction: Unstable fractures of the distal tibia that are not suitable for intramedullary nailing are commonly treated by open reduction and internal þxation and/or external þxation techniques. Treatment of these injuries using minimally invasive plate osteosynthesis (MIPO) techniques may offer the advantage of achieving adequate þxation whilst minimising soft tissue injury and damage to the vascular integrity of the fracture fragments. Purpose: We report our experience using MIPO techniques for the treatment of unstable fractures of the distal tibia. Method: A review of all patients who sustained an unstable fracture of the distal tibia treated by MIPO between 1998 and 2001 was undertaken. Twenty patients were identiþed. The mean age was 38.3 years (17 Ð 71). All fractures were closed, and were classiþed according to the AO system. Intra-articular fracture extensions were classiþed according to RŸedi and Allgšwer. Results: Sixty percent of patients achieved callus by 8 weeks. All patients achieved callus by 3 months. The mean time to full weight bearing was 12 weeks (8 Ð 17). By 6 months 18/20 patients had achieved union. The two remaining patients achieved union by 7 months without further surgery. There were no deep infections and only one malunion. There were no cases of failure of þxation. Conclusion: MIPO appears to offer a reliable method of þxation of fractures of the distal tibia that are unsuitable for intramedullary nailing. Our results suggest that this technique is associated with a lower risk of signiþcant complications than encountered with more traditional methods of þxation of such fractures

Endoprosthetic replacement of the distal tibia and ankle joint for a primary bone tumour is a rarely attempted and technically challenging procedure. We report the outcome of six patients treated between 1981 and 2007. There were four males and two females, with a mean age of 43.5 years (15 to 75), and a mean follow-up of 9.6 years (1 to 27). No patient developed a local recurrence or metastasis. Two of the six went on to have a below-knee amputation for persistent infection after a mean 16 months (1 to 31). The four patients who retained their endoprosthesis had a mean musculoskeletal tumour society score of 70% and a mean Toronto extremity salvage score of 71%. All were pain free and able to perform most activities of daily living in comfort. A custom-made endoprosthetic replacement of the distal tibia and ankle joint is a viable treatment option for carefully selected patients with a primary bone tumour. Patients should, however, be informed of the risk of infection and the potential need for amputation if this cannot be controlled

Aims: There has been recent interest in the use of external þxation for the treatment of distal peri-articular fractures. The current study was undertaken to evaluate the role of the hybrid external þxation system in the treatment of the distal tibial fractures. Methods: We treated 137 fractures of the distal tibia, of which 46 were treated with hybrid external þxation. The indication for this method of treatment was in the presence of an unstable extra-articular fracture and/or a severe comminution of the distal tibia, as well as an associated severe soft-tissue injury. Routine demographic data, clinical and radiographic þndings as well as reduction, outcomes and complications were recorded. Patients were evaluated with outcome scale of Ovadia and Beals. Results: There were 17 closed fractures and 29 open. Twenty-one extra -and 25 intrarticular fractures were managed with a Hybrid Fixator. All fractures achieved complete healing. Reductions of C-type fractures were within 0-2 mm in 16 and 3–5mm in 56 and > 5mm in 3 patients. The Hybrid External þxator was removed at an average of 17.5 weeks. Full weight bearing was achieved at a mean of 7.8 weeks. There were no intraoperative injuries to nerves or major vessels. Using the outcome scale of Ovadia and Beals, good-excellent results were achieved in 67% (n=31) subjectively and 72% (n=33) objectively. Two poor results occurred in patients with a varus malunion. Conclusion: External þxation is a satisfactory method of treatment for fractures of the distal tibia and is associated with fewer complications than internal þxation, because it limits the amount of soft tissue

Introduction: Primary or secondary bone tumours of the distal tibia are uncommon. Before the development of endoprostheses in the 1970’s, the primary treatment for these was below knee amputation. Limb salvage is now possible without adversely affecting survival largely due to improvements in chemotherapy. We report the clinical and functional outcome of six patients who underwent limb salvage with endoprosthetic reconstruction of the distal tibia and ankle joint for malignancy. Methods: Retrospective review of all patients who underwent limb salvage with endoprosthetic reconstruction of the distal tibia and ankle joint at our institution. Data was collected from the bone tumour database, medical records, imaging studies, clinic reviews and individual structured patient questionnaires. MSTS and TESS scores were used to assess functional outcome. Results: Six patients underwent distal tibial replacement for malignant bone tumours of the distal tibia. There were 4 males and 2 females with a mean age of 31.2 years (range 13 to 68) and mean follow-up of 35 months (range 13 to 76). One patient died of non-neoplastic disease at 76 months. Two patients had Ewings sarcoma, two had osteosarcoma, one had malignant fibrous histiocytoma and one had adamantinoma. No patient had metastases at presentation and no patient developed local recurrence or distant metastases post-operatively. Four patients developed infection, for which two required below knee amputation and two suppressive antibiotics. Hardware failure was seen in one patient with infection which was managed by below knee amputation. One patient required sub-talar fusion and calcaneal osteotomy for persistent ankle pain. A child who underwent the procedure age 13 developed a 5 cm leg-length discrepancy once skeletally-mature. Mean MSTS and TESS scores for the three patients who still had a functioning endoprosthesis were 77% and 79% respectively. Conclusion: Limb salvage with distal tibial combined with ankle joint replacement can be used as an alternative to below knee amputation in patients with bone tumours of the distal tibia. Due to the difficulties in achieving adequate soft tissue cover, patients should be counselled regarding the high potential complication rate which can lead to significant morbidity, functional deficit and further surgical intervention

Introduction and Aims: I was presented with a Land-mine victim with closed fracture of right talus, compound injury to left lower limb, and defect in heelpad. Distal third of tibia and most of hindfoot were missing. Left foot neurovascularly intact and he was able to move his toes. Aim: reconstruct left distal tibia to enable full weight-bearing. Method: Lower leg debrided. LRS applied, using proximal ring with Sheffield clamp and two rings around foot. Corticotomy of proximal tibia. Bone transport, 10 days later. Heel debridement, to clear necrotic bone. Two months later transported bone was 2cm from ankle. Sepsis controlled. Distal tibia beveled, bone transport continued. Docking procedure performed. Ex-fix adjusted, attaining compression of hindfoot and midfoot. Distal tibia and foot transported 4cm, to correct disproportion. Osteoset used for bone growth. During the following two years, length discrepancy resolved, sepsis manageable. X-rays showed two cortices between proximal tibia and transported tibia. Fixator removed two months later. Received orthotic boot. Results: In September 2003 the patient came for follow-up. There was no evidence of sepsis in the leg. He was full weight-bearing using an orthotic shoe and rocker bottom sole. There was no pain. He had left the army and was now working as a builder in his country of origin and putting in a whole day’s work. The length of the transported segment is approximately 14cm. It is now fully consolidated and four cortices are visible on x-ray. The fusion of the distal tibia into the foot is solid and no pain is experienced from that. Conclusion: Big defects in the distal tibia can be managed with a straight rail reconstruction system, using unifocal bone transport with proximal corticotomy

Introduction. Posterior malleolar fractures are present in up to 44% of all ankle fractures. Those involving > 25% of the articular surface have a higher rate of posterior ankle instability which may predispose to post traumatic arthritis. The posterolateral approach to the distal tibia allows direct reduction and stabilization of the posterior malleolus and concomitant lateral malleolus fractures. An anatomical study was performed to establish the safe zone of proximal dissection to avoid injury to the peroneal vessels in this uncommon approach. Methods. 26 unpaired adult lower limbs were dissected using the posterolateral approach to the distal tibia as described by Tornetta et al. The peroneal artery was identified coursing through the intraosseous membrane on deep dissestion as the flexor hallucis longus muscle was reflected medially. The level of its bifurcation was also noted over the tibia. Perpendicular measurements were made from the tibial plafond to these variable anatomical locations. Results. The peroneal artery bifurcated at 83+/−21 mm (41–115mm) proximal to the tibial plafond and perforated through the interossoeus membrane 64+/−18 mm (47–96mm) proximal to the tibial plafond. Conclusion. The safe zone for the posterolateral approach to the distal tibia is described. Caution is advised as the bifurcation and perforating artery may be as little as 41mm from the tibial plafond. This is important during deep dissection when the belly of the flexor hallucis longus muscle is reflected medially from the medial edge of the fibula. Once the peroneal artery was mobilized a buttress plate could easily be placed beneath it

Purpose: Amputation is often proposed for malignant tumours of the distal tibia. The purpose of our study was to report outcome and complications after conservative treatment of osteosarcoma of the distal tibia. Material and methods: Eight patients, four boys and four girls aged 8 – 16 years (mean 12 years) were managed conservatively with high-dose methotrexate chemotherapy for osteosarcoma of the distal tibia between 1983 and 1998. Wide resection was performed in all cases and one patient had a lung metastasis. Mean length of resection was 13 cm (9–19). Tibiotalar reconstruction arthrodesis was performed in seven patients. Tibial grafts and a centromedullar nail associated with fibulotalar arthrodesis with screw fixation were used in four patients. Plate fixation was used in two, and one patient had a cement spacer while waiting for biological reconstruction. After surgery, the patients were immobilised in a plaster cast for three to six months. Weight bearing began two to four months after surgery. Results: Resection was wide in four cases, marginal in three , and contaminated in one. Four patients responded well to chemotherapy and four responded poorly. Outcome was assessed at a mean follow-up of 5.5 years (2–17 years). At last follow-up, six patients were in remission, and two had died, including one after local recurrence despite amputation. Three patients had a deep infection which cured in all three without surgery. Two revisions were required in one patient with nonunion before achieving a solid union. All the patients who had a tibiotalar arthrodesis progressively developed nearly normal “ankle” function subsequent to progressive sub-talar hypermobility. The mean MSTS score was 27.7/30 (range 22 – 30). Discussion: Conservative management of osteosarcoma of the distal tibia appears to be feasible and provides excellent functional results despite an important risk of infection. Wide surgical margins requires a good response to chemotherapy. In case of doubt, reconstruction must avoid contaminating the rest of the tibia in order to allow secondary amputation if needed

Distal tibia and ankle sepsis can threaten the viability of the limb. We present the management protocol and results in 37 patients with chronic infection of the distal tibia and ankle, followed up for a mean of 4 years. The mean age was 45.6 years. Host type A were 21 patients, type B were 9, and type C were 7 patients. Treatment included radical debridement, multiple cultures sampling and local antibiotic application. Twenty seven patients required bone stabilisation, whereas 3 host C patients were amputated. Soft tissue coverage included 5 free muscle flaps, 3 soleus flaps and 5 pedicle fasciocutaneous local flaps. Bone defects of a mean of 6.3 cm (3–13cm) in 20 cases were treated with distraction histogenesis (13 cases) or the free fibula vascularised graft (7 cases). Mean hospitalisation time was 26.2 days (host-A: 19.6 vs. host B/C: 32.2, p=0.036). Host-A patients required 2.3 operative procedures whereas host-B/C 3.9 (p=0.01). Union occurred in 26/27 (96%) of cases requiring fixation (one ankle arthrodesis revision/host-B patient). External fixation frames were kept in situ for a mean of 31.7 weeks (12–85). Mean leg length discrepancy was 0.6 cm. Ankle arthrodesis was performed in 7 patients (5% among host-A patients vs. 38% among B/C). Independent ambulation was achieved in (35/37) 95%. All patients were satisfied with the result. Bacteriology revealed Staph. aureus in 71%, whereas 38% were polymicrobial (7% in host-A vs. 88% in B/C patients, p< 0.001). Infection recurrence occurred in 5.4% (none in host-A vs. 13% in B/C patients, p=0.03), whereas the overall complication rate was 43% (24% in host-A vs. 75% in B/C patients, p=0.02). Functional limb salvage without leg length discrepancy was possible in 92% of cases. Systemically compromised patients required longer hospitalisation, more operative procedures, had frequently polymicrobial infections and more complications

We report the results of limb salvage for non-metastatic osteosarcoma of the distal tibia using resection arthrodesis, autogenous fibular graft and fixation by an Ilizarov external fixator. In six patients with primary osteosarcoma of the distal tibia who refused amputation, treatment with wide en bloc resection and tibiotalar arthrodesis was undertaken. The defect was reconstructed using non-vascularised free autogenous fibular strut graft in three patients and a vascularised pedicular fibular graft in three, all supplemented with iliac cancellous graft at the graft-host junction. An Ilizarov external fixator was used for stabilisation of the reconstruction. In five patients sound fusion occurred at a mean of 13.2 months (8 to 20) with no evidence of local recurrence or deep infection at final follow-up. The mean post-operative functional score was 70% (63% to 73%) according to the Musculoskeletal Tumour Society scoring system. All five patients showed graft hypertrophy. Union of the graft was faster in cases reconstructed by vascularised fibular grafts. One patient who had a poor response to pre-operative chemotherapy developed local tumour recurrence at one year post-operatively and required subsequent amputation

Fractures of distal tibia are common and often present with dilemma of appropriate and safe management. The use of locking plates has changed the way these fractures have been managed as it avoids extensive soft tissue dissection and periosteal stripping. The aims of this study were to look at the results of stabilization and analyse the complications of fractures of distal tibia treated with Locked plates. We carried out a retrospective study of patients who underwent surgical treatment for distal tibial fractures using MIPO (Minimally invasive Percutaneous Osteosynthesis) technique. The data was gathered from theatre data base. We studied a period between Nov 2006 to May 2009. We collected patient demographics as well as the type of fractures, mechanism of injury, radiological union and associated complications. There were no open fractures in the study. The limb was splinted for two weeks after surgery in a back slab. The patients were followed up at 6 weeks, 3, 6, 9 and 12 months after surgery. There were 45 patients in the study with 29 males & 16 females between ages of 20 – 87 (avg. 49 yrs). 24 patients sustained injury due to a fall, 12 were involved in RTA and the remaining 9 were sports related injuries. The mean time to surgery was 3.15 days (1 – 7) and surgery was carried either by the consultant or their direct supervision. The mean hospital stay was 7 days (2 – 35) and mean time to radiological evidence of callus was 9 weeks. All patients eventually returned to their preinjury employment. 76% showed radiological union at 6 months and 90% at 9 months. There were 3 superficial wound infections, 2 deep infections whilst 2 needed bone grafting and 1 implant failure. 2 patients developed mild form of CRPS which resolved at 12 months. 11 patients had metal discomfort of which 9 had removal of hardware. All these patients had the tip snapped off. MIPO with LCP is a reliable and reproducible technique in treatment of closed unstable fracture of distal tibia. Patients must be counselled about implant removal after fracture union. Avoid snapping the tip of the LCP

Wire crossing angle affects the stability of circular fine wire frames. Anatomical atlases document safe ‘corridors’ to avoid neurovascular structures, although this may limit crossing angle. In the distal tibia the furthest posteriolateral safe corridor described is through the fibula. The present study describes a new and safe ‘retro-fibular’ corridor for wire placement in the distal tibia that provides a greater crossing angle. Two different methods of wire insertion are considered to determine which provides greater protection to neurovascular structures. A dissection based study of 20 embalmed lower limbs divided into two groups. 1.8mm wires were inserted at increments along the tibia, from posterolateral to antero-medial, at 30–45 degrees to the sagittal plane. In the first group wires were placed against the posterior surface of the fibula and ‘stepped’ medially onto the tibia. In the second wires were inserted midway between the border of the fibula and tendoachilles. Standard dissection techniques were used to identify the path of wires and distance from neurovascular structures. In group one distal tibial wires avoided the posterior tibial neurovascular bundle (mean distance 21.7mm) although passed close to the peroneal artery (mean distance 1.2mm). In group two both the posterior tibial and peroneal structures were avoided (mean distances 15.5mm and 7.1mm respectively). Comparison of the two groups shows a significant difference (p< 0.001). Retrofibular wire placement is safe in the distal quarter of the tibia and facilitates an optimal crossing angle, although is not described in standard atlases. Insertion of wires mid-way between the posteromedial border of the fibula and the tendoachilles appears the most reliable technique

Aim. The aim of this study was to compare the cost-effectiveness of intramedullary nail fixation and ‘locking’ plate fixation in the treatment of extra-articular fractures of the distal tibia. Patients and Methods. An economic evaluation was conducted from the perspective of the United Kingdom National Health Service (NHS) and personal social services (PSS), based on evidence from the Fixation of Distal Tibia Fractures (UK FixDT) multicentre parallel trial. Data from 321 patients were available for analysis. Costs were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality adjusted life year (QALY) gained, and net monetary benefit. Sensitivity analyses were conducted to test the robustness of cost-effectiveness estimates. Results. Mean NHS and PSS costs were significantly lower for patients treated with an intramedullary nail than for those treated with a locking plate (-£970, 95% confidence interval (CI) -1685 to -256; p = 0.05). There was a small increase in QALYs gained in the nail fixation group (0.01, 95% CI -0.03 to 0.06; p = 0.52). The probability of cost-effectiveness for nail fixation exceeded 90% at cost-effectiveness thresholds as low as £15 000 per additional QALY. The cost-effectiveness results remained robust to several sensitivity analyses. Conclusion. This trial-based economic evaluation suggests that nail fixation is a cost-effective alternative to locking plate fixation. Cite this article: Bone Joint J 2018;100-B:624–33

Introduction: An important factor affecting the stability of circular fine wire frames is the wire crossing angle, where an angle of 90 degrees confers optimal stability. Safe anatomical ‘corridors’ have been described to avoid neurovascular structures, but often limit the crossing angle. In the distal tibia the posterior tibial artery and tibial nerve wind medially facilitating safe placement of a posterior to anterior ‘retrofibular’ wire. The present study aims to identify structures at risk during ‘retrofibular’ wire placement and determine the level at which this can be used safely. Methods: A dissection based study of 10 embalmed lower limbs. Wires of 1.8mm diameter were inserted at increments along the tibia. These were placed against the posterior surface of the fibula and ‘stepped’ medially past the posteromedial border onto the tibia. Wires were introduced from posterior to anterior, between 30 degrees and 45 degrees to the sagittal plane. This angle is estimated, reproducing clinical practice. Standard dissection techniques were used to identify the path of wires and distance from neurovascular structures. Results: In the distal quarter of the tibia wires avoided the posterior tibial neurovascular bundle (mean distance 21.7mm) although passed close to the peroneal artery (mean distance 1.2 mm). Of the 30 wires placed in the distal tibia, 29 (97%) passed through the leg without damage to any neurovascular structures. Anterior tendons were tethered by 13% of wires placed in the distal quarter of the tibia. Discussion: Retrofibular wire placement facilitates an optimal crossing angle, although is not described in standard atlases. Use in the lower quarter of the tibia does not threaten the posterior tibial neurovascular bundle. However, peroneal artery injury is a possibility. The clinical significance of peroneal artery injury at this level is unclear but should be considered when using this technique

Most high-energy trauma to lower legs, ankles and feet result in severe crush injuries. We performed a retrospective case series study. Eight patients (7M: 1F) with mean age of 28 years (range -18 -35 years) were included. Four had Grade 3 open fractures of the distal tibia and 5 had open foot fractures. Two had neurovascular injuries. Four patients had associated injuries with mean ISS of 9 (range 8-16) and a mean MESS score of 3.5 (3-7). All had undergone some form of internal and external fixation within approximately 24 hours (8 hrs to 4 days). The mean follow-up period was two years (range 1-4 years). At final follow-up patients' health was measured using SF-36 questionnaire. Six patients had their fractures healed at a mean of 4.8 months (4-9 m). Two patients had fully functional foot with occasional complaints of painful ankle. Two patients had CRPS1 undergoing treatment. Two patients are unable to walk due to chronic pain and deformity. Comparison of the SF-36 scores with the age-matched UK normal controls without foot and ankle injuries showed significantly worse scores in physical function (PF: p<0.01) and role physical (RP: p< 0.01) categories. Our surgical instinct dominates decision-making, favouring salvage rather than amputation in these young groups of patient. They gradually suffer a cocktail of crippling disease characterised by psycho-socio-economic and physical disability. Should we be depleting our resources in salvaging these complex limb injuries?

Non-unions of pilon fractures are difficult Orthopaedic problems. Significant bone loss and infection can lead to amputation. Joint stiffness in conjunction with disuse osteopenia make stabilization in this area challenging. We present the use of a custom blade plate design that offers sufficient stability for successful treatment in six successive cases. With a mean follow-up of thirty-three months, all fractures treated with this method healed. The five infected cases healed without recurrence of infection. With average scores of 70.7 on the Maryland Foot Score, and sixty-eight on the Foot and Ankle Society Ankle-Hindfoot Scale, the patients overall had satisfactory results. The purpose of this study was to describe a new technique of treating non-unions of distal tibia pilon fractures using a custom blade plate design. A report of successful outcomes in six consecutive cases. A retrospective analysis of fifty-six pilon fractures treated over a three- year period revealed six patients with significant complications related to their fractures. Of these, all had significant bone loss and five were infected. All six failures were revised using a custom blade plated design with oblique locking screws for triangular fixation of the distal pilon. The average follow-up period was thirty-three months. These patients were evaluated with the Maryland Foot Score (MFS) and the Foot and Ankle Society Ankle-Hindfoot Scale (AHS). All of the six patients treated with the proposed method went on to heal without recurrence of infection. Three patients required additional surgical interventions including bone grafting, debridement and hardware removal to achieve the final result. Their average MFS and AHS were 70.7 and sixty-eight respectively. Stable fixation is an absolute necessity for a successful outcome in the failed pilon fracture. A custom blade plate design with oblique interlocked screws offers sufficient long-term stability, despite infection and disuse osteopenia, for healing of the non-united fracture to occur. As shown by our series, satisfactory clinical results can be expected and amputation can be avoided in complicated cases using this surgical technique

A series of 3061 patients with fracture of the distal tibia or ankle was studied for a possible link between overweight and failed reduction. The relative body-weight was recorded as the preoperative self-reported body mass index (BMI) of each patient. There were 109 patients (3.6%) with failure of internal fixation or of closed reduction severe enough to necessitate refixation or corrective osteotomy. The mean BMI in all age- and gender-specific groups studied was found to be significantly higher in patients with failed reduction than in those with an uneventful course (p < 0.01). The relative risk of loss of reduction for patients with a BMI greater than 1SD above the BMI of the corresponding age and gender group of the general population was 3.72 for distal tibial fractures and 3.04 for ankle fractures. Overweight should be recognised as a significant factor in predicting a complicated course after a fracture of the lower leg. Awareness of the increased risk of loss of reduction in overweight patients is important in all phases of management

Surgical treatment of distal tibia fractures is usually associated with extensive soft tissue compromise and high complication rates (infection, delayed or non-union, ankle stiffness and osteoarthritis). Wound infection is one of the most common complication (deep infection rates up to 15%) and can develop into an infected non-union. In 1973, Papineau described a staged technique for treating infected non-union of long bones, consisting of (1) surgical debridement of necrotic tissue, temporary splinting, specific antibiotic treatment, postoperative wet-to-dry wound dressing changes; (2) packing of the bone defect with cortico-cancellous autograft; (3) closure of the soft-tissue wound by a flap or secondary intent. The authors aim to report a clinical case of a successful treatment of a distal tibia infected non-union with the Papineau technique and negative-pressure wound therapy. Woman, 56 years-old, referred to Orthopaedic consultation on October 2013 for wound dehiscence and infection with a methicillin-resistant Staphylococcus aureus, one month after open reduction and internal fixation of an open distal tibia fracture. On November 2013 she underwent surgical debridement, removal of osteosynthesis material, osteotaxis with external fixator, negative-pressure wound therapy and antibiotic treatment with intravenous vancomycin 1g 12/12h (1st stage of Papineau procedure). On December, she underwent autologous iliac crest cancellous bone grafting and wound care, daily irrigated with saline solution (2nd stage). On February 2014, she underwent a partial thickness skin graft for wound closure (3rd stage). On April, the external fixator was removed and there was still no evidence of union. She had pain, disuse osteoporosis, ankle and midfoot stiffness, and was sent to physical therapy. On April 2015, she can full weight bear with mild pain, the soft tissue envelope is in good condition, the fracture has united and she has an Ankle AOFAS Score of 83. The Papineau technique has been used for the management of infected non-unions with bony defects, with high success rates. Complete necrotic tissue debridement and targeted antibiotics are fundamental for obtaining a viable and healthy tissue, able to receive the bone graft. Negative-pressure wound therapy is important in reducing the bacterial load, improving the microcirculation and enhancing the granulation tissue. In the present case, the combination of the two techniques probably acted together in achieving successful eradication of the infection, reconstruction of the bone defect and soft tissue closure

Distal tibial bone loss involving the ankle is a devastating injury with few options for reconstruction. The purpose of our study was to look at the long term results of ilizarov technique used to achieve lengthening of tibia and fusion at the ankle. 17 cases (16 post traumatic and one post tumor resection) admitted to one institution between 1994 and 2003. 13 cases were done in bifocal and four in trifocal mode. The duration of follow up was 12 to 84 months The average age was 33 years (Range 7–71). The mean length of the defect was 4.5 cm (Range 1–12). Union of the fusion site occurred in 88% (15/17) of the patients with mean duration to docking and union being 8 months. The mean time in fixator was 13 months (Range 5 to 29). Average number of surgeries per patient was 3.2. Five patients required free vascularised grafts before the index procedure and 4 patients required realignment at the docking site. Functional results – Fourteen (77.5%) of the patients could walk without support or bracing and twelve patients (71%) returned to same or modified occupation. Complications – Two non-union. Deformity – Fusion site equinus deformity occurred with non union after re-fracture in one case. There were 2 cases of residual fore-foot equinus. Residual low grade infection with discharging sinus was present in two patients. One patient needed change of wires for Pin tract infection. Our study showed 76% good and excellent scores on functional scoring but also demonstrates the high morbidity associated with this procedure. In spite of the steep learning curve and high complication rates the procedure can be undertaken in specialised centers for highly motivated patients to achieve good functional results

A series of 49 pilon fractures in a tertiary referral centre treated definitively with open reduction and internal fixation have been assessed examining the complications associated with such injuries. A retrospective analysis of casenotes, radiographs and computerised tomographs over a seven year period from 1999–2006 was performed. Infection was the most common post operative problem. There were 7 cases of superficial infection. There was a single case of deep infection requiring intravenous antibiotics and removal of metalwork. Other notable complications were those of secondary osteoarthritis (three cases) and malunion (one case). The key finding of this paper is the 2% incidence of deep infection following the direct operative approach to these fractures. The traditional operative approach to such injuries (initially advocated by Ruedi and All-gower) consisted of extensive soft tissue dissection to gain access to the distal tibia. Our preferred method is to gain access to via the “direct approach” which involves direct access to the fracture site with minimal disturbance of the soft tissue envelope. We therefore believe open reduction and internal fixation of pilon fractures via the direct approach to be an excellent technique in the treatment of such injuries

Aims: Nonunions of the distal tibia are difþcult to treat due to the short distal segment, the proximity to the ankle joint and the fragile soft tissue envelope. Intramedullary nailing is an attractive solution as it avoids extensive soft tissue dissection and remains intraosseus, posing little problem for the soft tissues. The purpose of this study was to determine the efþcacy of reamed intramedullary nailing in the treatment of non-unions of the distal one-quarter of the tibia. Methods: Thirty-two patients with nonunions of the distal one-quarter of the tibia were treated by reamed, locked intramedullary nailing. Prior treatments included casting as well as intramedullary or extramedullary þxation techniques. No patient had signs of an active infection at the time of surgery. Time to union, correction of deformity and complications including infection and reoperation were examined. Results: Twenty-nine out of thirty-two patients achieved union at an average of 3.5 months after surgery. Of the remaining three, two patients united rapidly after dynamisation and one after exchange nailing. Deformity was corrected to a maximum of four degrees in all planes. Four patients had positive intraoperative culture, and only two required removal of the nail after achieving union to eradicate infection. There were no cases of chronic osteomyelitis after the procedure. Conclusions: Reamed, locked intramedullary nailing is a reliable and safe procedure in the treatment of nonunions in the distal one-quarter of the tibia. It allows for excellent correction of deformity, which is an essential component of the procedure

We have reviewed 15 cases of triplane fracture of the distal tibia. The mechanism of injury is lateral rotation and the anatomical pattern of the fracture depends on the state of the growth plate at the time of injury. In seven of our cases the anteromedial part of the growth plate was fused, but in eight children the plate was completely open. In six of these eight children there was a hump or projection of the medial growth plate. It is suggested that this hump stabilises the anteromedial part of the epiphysis in a manner similar to the partial anteromedial fusion seen in older children, and that this accounts for the occurrence of triplane fracture in the presence of an open growth plate

Fractures of the distal tibia metaphysis comprise a challenge for the orthopaedic trauma surgeon because of the poor blood irrigation they do not heal very easy leading sometimes to pseudarthrosis and many times arise problems with the skin. We compare the following techniques: LC-DCP and LCP plates, MIPO, External fixators (hybrids or simple one), intramedullary nailing with multiple screws at the distal end. 94 cases of distal tibia fractures from all AO types were treated during last 3 years (2005–2008) with the following techniques:. 16 ORIF with LC-DCP plates. 9 ORIF with LCP plates. 19 MIPO. 35 External fixators. 15 intramedullary nailing. The simple oblique or spiral fractures which treated with the 1st and 2nd method (ORIF), they do not seem any remarkable difference in healing but both methods demonstrate a delay in fracture healing over 5 months. The 3rd method display faster healing 2,5 months average in simple fractures with no skin wound at all. The 4th method display 3 pin track infections and dealt with removal of the material and 2 pseudarthrosis which encountered with ORIF and bone grafting from the iliac. The 5th method display 2 malunions but because of the small angle in varus we do not perform any treatment. Every technique has its own position on those type of fractures, depending of the personality of the fracture and the skill of the surgeon

Percutaneous plating of the distal tibia via a limited incision is an accepted technique of osteosynthesis for extra-articular and simple intra-articular distal tibia fractures. In this study we identify structures are risk during this approach. Method. Thirteen unpaired adult lower limbs were used for this study. Thirteen, 16-hole synthes®LCP anterolateral distal tibial plates were percutaneously inserted according to the manufacturer instructions and confirmed by xray. Dissection was performed around the plate to examine the relation of nerves and soft tissue. Results. The neurovascular bundle was under the plate in one case. Over the horizontal limb of the plate, typically the superficial peroneal nerve had a variable course over all four screw holes. The anterior tibial artery coursed over hole number 3 and the Extensor hallucis longistendon was positioned over hole 3 or 4. The Anterior tibialis tendon skirted hole 4 in 12 cases. Over the vertical limb of the plate, the neurovascular bundle coursed over holes, 5 to 7, the superficial peroneal nerve over holes 5 to 7. Discussion. Meticulous attention is required when placing an anterolateral distal tibia plate using a MIPO technique. We recommend a larger initial incision to avoid entanglement of the superficial peroneal nerve under the plate. Over the anterior aspect of the tibia, an open technique with adequate neurovascular structure and tendon protection is necessary due to the variability of structure coursing over the plate. A bridging technique for placement of proximal locking screw should be made through a mini open incision and this is safe to do so proximally over holes 12 to 16. Caution is advised during placement of screws percutaneously from holes 1 to 12 however the neurovascular bundle courses commonly over holes 5 to 7. These landmarks also apply to the use of shorter anterolateral distal tibial plates

This study identified imaging parameter(s) which best predict the mechanical properties of distal tibia. Seventeen human cadaver tibiae were assessed by PQCT at four, eight and ten percent site from distal and tested in compression at the twenty-five percent distal portion. Ultimate compressive loads were recorded with a mean of 8276 ± 2915 N. Spearson rank correlation and stepwise regression analysis revealed that CoA, total BMC, SSI and SSI4-TrA4-CoD4 combination had statistically significant correlations with the failure loads. Among all imaging parameters, SSI had the highest relevance due to its account for geometry, density and material distribution, important factors for structural properties. Musculoskeletal diseases, especially hip fractures, have huge and growing impact on Canadian society. To develop techniques for identification of high risk population, we needed a link between clinical evaluations and laboratory measures of bone health. This study identified imaging parameter(s) which best predict the mechanical properties of distal tibia. Seventeen human cadaver tibiae were considered in this study (mean age seventy-four, SD six years). PQCT was used to assess the four, eight and ten percent site. It measured the cross-sectional area, bone mineral content and bone mineral density of the cortical bone, trabecular bone and combined. Strength Strain Index (SSI) was calculated from these measurements. Each tibia was cut at twenty-five percent distal. Compressive force was applied uniaxially through a custom-made PMMA indentor onto the distal plateau along the longitudinal axis of the tibia at a rate of 10mm/s. Load and displacement data were recorded. Spearson rank correlation and stepwise regression analysis were used to identify individual and combination of imaging variables that were related to ultimate failure load. Ultimate failure loads were recorded with a mean of 8276 ± 2915 N. Cortical area (R_0.72), total BMC (R_0.72) and SSI (R_0.86) had statistically significant correlations with the failure load. Stepwise regression revealed that the combination of SSI, TrA, CoD at 4% site explained the greatest amount of variance (R2 = 0.868) and SSI was the major contributor. SSI takes the polar moment of inertia (geometry), density and distribution of material into account. This explains its relevance towards predicting the ultimate failure load. Please contact author for referenced images

Unstable fractures of the distal tibia are being increasingly treated by open reduction and internal fixation using pre-contoured locking plates. Functional outcome following this type of fixation has not been reported previously. The aim of this study was to functionally assess patients following MIPO fixation of distal tibial fractures. Case notes of 26 patients treated at a single centre were reviewed. The fracture type, fixation technique, complications, time to union and subsequent treatment were documented. All patients returned for functional scoring using the validated American Academy of Orthopedic Surgeons (AAOS) foot and ankle core score. Twenty-six consecutive patients were treated between 2002-2005. The majority were male, and 5 were open fractures. There were 13 AO type A, 4 type B and 9 type C fractures. Mean follow up was 20 months. Average time from injury to surgery was 2.5 days. All fractures were treated by a MIPO technique. A pre-contoured distal locking plate was used for the distal tibial reconstruction. Secondary surgical procedures e.g. 2nd look, delayed primary closure, or skin grafting were necessary in 3 cases. The fibula was plated in 60% of cases. Four patients developed wound infections requiring antibiotics, and all resolved. The commonest rehabilitation regime was 6 weeks non weight bearing in plaster. Mean time to union was 18 weeks. There were 3 cases of delayed union, requiring bone grafting. One patient required removal of the plate due to local irritation, and one required a broken screw to be removed. Mean range of movement was 10 degrees dorsiflexion, 30 plantarflexion. The mean normalised AAOS foot and ankle core score was 41 (SD +/− 8). We conclude that MIPO fixation of distal tibial fractures is a safe and effective method of treatment. Functional outcome does not significantly differ from that of the general population

The treatment of high energy fractures of distal tibia by internal fixation is followed by a high rate of soft tissue complications. The result estimation of these fractures in a two stage treatment, bridging the ankle by Ex-Fix with/without internal fixation of the fibula and internal fixation of the tibia after soft tissue recovery. In a 4 year period (2005–8), 15 patients, average of 42 years were treated. The AO fracture classification was followed. The soft tissue damage estimation (Osternn-Tscherne and Gustillo classification), the fracture pattern of the fibula and the injury mechanism consisted of the choice method criteria. The majority of the injuries was classified Tscherne II & III, and 3 open fractures Gustillo II. Fracture reduction was performed by bridging Ex-Fix of the ankle with/without plating the fibula with a 1/3 or DCP 3.5 mm plate. Definite internal fixation of the tibia by locking plate was performed from 8th –14th postoperative day after soft tissue recovery. Preoperatively CT scan was performed with grate significance, defining the soft tissue condition, the surgical approach and the osteosynthesis type. Follow up average 14 months. None of the patients developed infection. All wounds were healed in one stage. Superficial skin necrosis was conservatively treated in two patients. Soft tissue complications, after internal fixation of high energy fractures of the distal tibial, usually appear. Two stages treatment allows better preoperative planning, immediate patient mobilization and reduce complication rate

This paper describes the outcome of type III pilon fractures of the distal tibia treated primarily with an llizarov ring fixator. Only patients with intra-articular fracture of the tibial plafond on plain radiographs that corresponded to type III pattern of Ruedi and Allgower were included. There were thirteen patients with a mean age of 45 (range 29–65), twelve males and one female. The mechanism of injury in all the patients was high-speed road traffic accident. Operative fixation consisted of fracture reduction and stabilisation using the Ilizarov circular frame external fixator and olive tipped wires. Further insult to the already damaged soft tissues was avoided. Bony union was achieved in all cases. Treatment in the frame lasted between 3 and 10 months (average of 6.3 months). Neither deep infection nor soft tissue complications occurred. Outcomes measured using the Olerud ankle score, modified Ovadia and Beals radiological criteria, and the SF-36 Health Questionnaire and our results compare well with other fixation techniques. The use of the llizarov circular frame external fixator without any additional internal reduction or fixation procedures is a definite option for the treatment of these high-energy injuries

This paper describes the outcome of type III pilon fractures of the distal tibia treated primarily with an Ilizarov ring fixator. Only patients with an intra-articular fracture of the tibial plafond on plainradiographs that corresponded to type III pattern with the system of Rfiedi andAllgower were included. There were thirteen patients with a mean age of 45 (range 29–65), twelve males and one female. The mechanism of injury in all the patients was high-speed road traffic accident. Operative fixation consisted of fracture reduction and stabilisation using the llizarov circular frame external fixator and olive tipped wires. Further insult to the already damaged soft tissues was avoided. Bony union was achieved in all cases. Treatment in the frame lasted between 3 and 10 months (average 6. 3 months). Neither deep infection nor soft tissue complications occurred. Outcome measurements included the Olerud ankle score, modified Ovadia and Beals radiological criteria, and the SF-36 Health Questionnaire. Wound and deep infections were successfully avoided and bony union was achieved in all our patients. This compares well with other fixation techniques. The use of the llizarov circular frame external fixator without any additional internal reduction or fixation procedures is a definite option for the treatment of these high-energy injuries

Distal tibial bone loss involving the ankle is a devastating injury with few options for reconstruction. The purpose of our study was to look at the long term results of ilizarov technique used to achieve lengthening of tibia and fusion at the ankle. 17 cases (16 post traumatic and one post tumor resection) admitted to one institution between 1994 and 2003. 13 cases were done in bifocal and four in trifocal mode. The duration of follow up was 12 to 84 months The average age was 33 years (Range 7-71). The mean length of the defect was 4.5 cm (Range 1-12). Union of the fusion site occurred in 88 % (15/17) of the patients with mean duration to docking and union being 8 months. The mean time in fixator was 13 months (Range 5 to 29). Average number of surgeries per patient was 3.2. Five patients required free vascularised grafts before the index procedure and 4 patients required realignment at the docking site. Functional results – Fourteen (77.5%) of the patients could walk without support or bracing and twelve patients (71%) returned to same or modified occupation. Complications – Two non-union. Deformity – Fusion site equinus deformity occurred with non union after re-fracture in one case. There were 2 cases of residual fore-foot equinus. Residual low grade infection with discharging sinus was present in two patients. One patient needed change of wires for Pin tract infection. Our study showed 76% good and excellent scores on functional scoring but also demonstrates the high morbidity associated with this procedure. In spite of the steep learning curve and high complication rates the procedure can be undertaken in specialised centres for highly motivated patients to achieve good functional results

Salter-Harris II fractures of the distal tibia affect children frequently, and when they are displaced present a treatment dilemma. Treatment primarily aims to restore alignment and prevent premature physeal closure, as this can lead to angular deformity, limb length difference, or both. Current literature is of poor methodological quality and is contradictory as to whether conservative or surgical management is superior in avoiding complications and adverse outcomes. A state of clinical equipoise exists regarding whether displaced distal tibial Salter-Harris II fractures in children should be treated with surgery to achieve anatomical reduction, or whether cast treatment alone will lead to a satisfactory outcome. Systematic review and meta-analysis has concluded that high-quality prospective multicentre research is needed to answer this question. The Outcomes of Displaced Distal tibial fractures: Surgery Or Casts in KidS (ODD SOCKS) trial, funded by the National Institute for Health and Care Research, aims to provide this high-quality research in order to answer this question, which has been identified as a top-five research priority by the British Society for Children’s Orthopaedic Surgery. Cite this article: Bone Joint J 2023;105-B(5):471–473

Aims: The evaluation of indications and results of the treatment of C fractures (according to AO) of the distal tibia with hybrid external þxation. Method: Between 1998–2001 thirty-one patients (22 men and 9 women), all available to follow-up, with 31 tibial pilon fractures were managed with hybrid external þxation. Mean follow-up time was 18 months and mean age 35 years (17–76). Seven were open fractures. Closed reduction (ligamentotaxis) and application of hybrid external þxation was done in 22 cases, while in 9 patients minimal open reduction, use of autologous bone grafts and minimal additional internal þxation was necessary. Mobilization of the ankle started at the 3rd postoperative day. The average time of healing was 4.2 months. Final evaluation was done according to evaluation criteria proposed by P. Tornetta III. Results: Fourteen patients (87%) had good and excellent, 2 (6.4%) fair and 2 (6.4%) poor. Complications were 1 valgus deformity > 8û, 1 nonunion, and 4 pin tract infections treated with p.o. antibiotics. Conclusions: Use of hybrid external þxation in C fractures allows anatomic reduction of the fragments with minimal invasion and immediate mobilization of the ankle join and early weight bearing. Open reduction is minimal and seldom needed. Pin site infection could occur

Purpose: To evaluate the outcome of salvage surgery with external fixation in these rare and severe lower limb injuries. Methods: Eight patients (7M: 1F) with mean age of 28 years (range −18 −35 years) were included. Four had Grade 3 open fractures of the distal tibia and 5 had open foot fractures. Two had neurovascular injuries. Four patients had associated injuries with mean ISS of 9 (range 8–16) and a mean MESS score of 3.5 (3–7). All had undergone some form of internal and external fixation within approximately 24 hours (8 hrs to 4 days). The mean follow up period was two years (range 1 – 4 years). At final follow-up patient’s health was measured using SF-36 questionnaire. Results: Six patients had their fractures healed at a mean of 4.8 months (4–9 m). Two patients had fully functional foot with occasional complaints of painful ankle. Two patients had CRPS1 undergoing treatment. Two patients are unable to walk due to chronic pain and deformity. Comparison of the SF -36 scores with the age-matched UK normal controls without foot and ankle injuries showed significantly worse scores in physical function (PF: p< 0.01) and role physical (RP: p< 0.01) categories. Conclusions: Our surgical instinct dominates the decision-making favoring salvage with external fixation primarily rather than amputation in these young groups of patient. Should we be depleting our resources in salvaging these complex limb injuries?

In a series of 126 consecutive pilon fractures, we have described anatomically explicable fragments. Fracture lines describing these fragments have revealed ten types of pilon fracture which belong to two families, sagittal and coronal. The type of fracture is dictated by the energy of injury, the direction of the force of injury and the age of the patient.

The aim of this study was to evaluate the results of a consecutive series of distal tibial fractures treated by percutaneous plating.

85 patients with distal tibial fractures were treated using minimally invasive medial plate fixation. 18 patients had open fractures. Eight had displaced intra-articular fractures (AO type 43C). The majority had extra-articular fractures (AO type 42 or 43A). Patients ranged in age from 16–89 years. All were followed to union with a minimum follow-up period of 6 months (average 47 months). Outcome measures assessed retrospectively were alignment, time to full weight bearing and complications including infection, delayed or non-union and secondary surgery.

The mean time to surgery after injury was 5 days (range 0–22). 51 patients had unlocked pre-contoured plates and the remaining 34 had locking plates. The fibula was plated in 41 cases. Post-operative mal-alignment greater than 5 degrees varus or valgus occurred in 3 cases (3.5%). The average time to full weight bearing was 11 weeks. Superficial infection occurred in 6 patients (7%) and deep infections in 4 cases (4.7%). There was one case of plate fracture. 4 patients, including this case, required further surgery to achieve union. There was a high rate of metalware symptoms that prompted plate removal.

Percutaneous plate fixation of distal tibial fractures is a reliable method of treatment with complication rates lower than reported for open techniques.

Aim: The aim of this study was to compare the treatment results of distal tibia shaft fractures treated with intramedullary nails with two different distal lockings and medial locking plates. Patients and Method: Sixty-four patients with distal tibia fractures (4 to 11 cm proximal to the plafond) were operated with either unreamed intramedullary nails with medio-lateral distal locking (group A) or unreamed intra-medullary nails with both medio-lateral and antero-posterior lockings (group B), or medial locking plates (group C). There were 22 patients in group A, 22 patients in group B and 20 patients in group C. Mean age was 48.53±17.07 years. Mean follow-up was 26.68±7.02 months. At latest follow-up groups were compared for union time, malunion (defined as more than 5 degrees of angulation in any planes and/or any rotation and/or more than 5 milimeters of shortening), and delayed (lack of healing within 3 months) or nonunion (lack of healing within 6 months). Uninon was defined as healing of at least three of four cortices on AP and lateral radiographs. Results: Mean union time was 17.45±4.22 weeks in group A, 16.71±4.90 weeks in group B and 15.73±3.26 weeks in group C. There was no significant difference between groups regarding union time. (p> 0.05) Malunion as defined was dedected in 4 patients in group A, in 4 patients in group B and in 1 patient in group C. There was no significant difference between groups regarding malunion rates. (p> 0.05). Delayed or non union was dedected in 6 patients in group A, in 5 patients in group B and in 1 patient in group C. There was no significant difference between groups regarding delayed or non-union. (p> 0.05). Two nonunions in group A and one nonunion in group B had to be treated with exchance reamed nailing. One infected nonunion in group C had to be treated with circular external fixation. Conclusions: The results of surgical treatment of distal tibia fractures are similar with these three diifferent methods. Although malunion and delayed or nonunion rates are lower with medial locking plates, this is not significant

Introduction:

In this cohort study, we present comprehensive injury specific and surgical outcome data from one of the largest reported series of distal tibial pilon fractures, treated in our tertiary referral centre.

A series of 76 distal tibial pilon fractures treated with surgical fixation were retrospectively reviewed from case notes, plain radiographs and CT imaging. Patient demographics, injury and fracture patterns, methods and timing of fixation and clinical and radiological outcomes were assessed over a mean follow up period of 8.6 months (range 2–30).

Definitive fixation was most commonly performed through an open technique (71 cases) with plate fixation. CT imaging was used to plan the most direct approach to access the fracture fragments. Single or double incision techniques were used to access the tibia, with fixation of the fibular performed when necessary.

Superficial infection occurred in 5 cases (6.9%) and deep infection in 2 (2.8%). Aseptic wound breakdown occurred in 5 cases (6.9%). The rate of wound breakdown after three-incision technique was 37.5%.

There were 10 cases of non-union (13.9%) and 8 of mal-union (10.5%). Post-traumatic arthritis was present on the most recent x ray in 17 cases (23.4%). Further surgery was required in 20 cases (27.8%), most commonly for metalwork related problems and also for treatment of non-union, post-traumatic arthritis and infection.

This review gives comprehensive injury specific and surgical outcome data from one of the largest reported series of these complex and problematic injuries.

Osteoid osteoma is a benign bone-forming lesion, characterized by its small size, its clearly demarcated outline and by the usual presence of a surrounding zone of reactive bone formation. It often poses a diagnostic challenge due to its ambiguous presentation. The aetiology of osteoid osteoma is poorly understood. The previous suggestion that osteoid osteoma was not associated with trauma or infection has been challenged by more recent literature raising the possibility that it could be a reactive or healing response or a phenomenon associated with the revascularisation process. This case report describes an unusual presentation of a post-traumatic osteoid osteoma. Two years following a diaphyseal, spiral tibial fracture treated nonoperatively, the patient developed new pain at the previous fracture site. The pain was constant, relieved by non-steroidal analgesia and not associated with systemic upset. It was initially attributed to other more likely diagnoses such as osteomyelitis and neuropathic pain. Multiple investigations and interventions were undertaken prior to the definitive diagnosis being obtained by surgical excision of the lesion and histological studies five years after the injury and three years following the initiation of the discomfort. In both English and foreign language literature there are only seven case reports that document osteoid osteoma following fracture, these are predominantly in the lower limb with no predominance to operative or nonoperative management. This case report should raise the index of clinical suspicion of osteoid osteoma occurring post fracture.

Background

Distal tibial metaphyseal fractures pose many complexities. This study assessed the outcomes of distal tibial fractures treated with percutaneously inserted medial locking plates.

This is an outcome study of the use of plate fixation for treatment of comminuted fractures of the distal third of tibia to determine prognostic factors such as age, sex, type of fractures, soft tissue injury and type of implant on healing.

Since 1999, a single surgeon (VP) has performed minimally invasive fixation in 18 patients for complex transitional fractures of the tibia. Follow up has been achieved by a combination of clinical and radiological assessment and notes review.

An overall excellent-good result was obtained in 17 of 18 patients. In one patient, the fixation was revised due to a 20 degree external rotation mal position. In two cases there was mild external rotation of 10 degrees. There were no infections.

The treatment of difficult juxta-articular fractures with a minimally invasive fixation is a useful management option. Peri-articular plates are easy to insert and give better results with respect to alignment correction.

Background. Tibial pilon fractures lead to complicated therapeutic problem. Application in these cases of external fixators which are composed of an active articulated joint hinge imitating movement in the region of upper ankle joint, which allows plantar and dorsal flexion, leads to functional treatment of distal tibia fractures.

Aim. The aim of the study was to present the four year experience with an evaluating biomechanical parameters, medical properties and clinical usefulness of the external fixator Dynastab-S in the treatment of tibial pilon fractures.

Material. Observations were based on patients hospitalized in Orthopedic and Rehabilitation Department of Medical University of Warsaw in a period from March 2000 to August 2004. The average period of observations was 29 months. Inclusion criteria were based on the algorithm which was created in our department.

Results. The assessment of biomechanical parameters of bone-fixator arrangement proved usefulness and safeness of the external fixator Dynastab-S. The positive results of clinical examinations, X-ray examinations and subjective opinion of the patients encourages to wide use of the external fixator Dynastab-S in the treatment of tibial pilon fractures.

Aims

The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols.

Aims

A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures.

Purpose of the study:. Is circular external fixation a safe and effective method of managing closed distal third tibia fractures. These fractures are conventionally treated with plaster casts, intramedullary nails or plate fixation. These treatment modalities have complication rates in the literature of up to 16% malunion, 12% non-union, and 17% deep infections. Description and Methods:. Retrospective review of 18 patients with closed distal third tibia fractures, with or without extension into the ankle joint, treated with circular fixator systems and minimal percutaneous internal fixation of the intra-articular fragment if required. Patients were followed up for time to union, malunion incidence as well as incidence of pin tract and deep infection. Distal third fractures which were extra articular or with simple intra articular extension were included. (AO 43 A, B1, C1, C2 + AO 42 in distal third) Patients with pilon fractures (AO 43 B2, B3 and C3) were excluded. Summary of results:. The average time to union in these patients was 16 weeks (11–33 weeks). The non-union rate was 11.1% in comparison to 12% with conventional treatment. The malunion rate was 0% compared to 16% with conventional treatment. The incidence of pin tract infection was 16.6%, but no deep infections were noted, whilst conventional treatment shows deep infection in up to 17%. Conclusion:. Circular external fixation is a safe and efficient option in the treatment of distal tibia fractures. The incidence of complications is significantly reduced in comparison to conventional treatment

In our cadaver study plating the fibula in addition to nailing the tibia decreased the mean rotation across the tibial osteotomy site compared to nailing the tibia alone. Although this is statistically significant (p=0.0034) it may not be clinically relevant as the mean values for ROM were 19.10 and 17.96 degrees respectively. Plating the fibula resulted in no statistically significant difference in the mean vertical displacement, angulation or neutral zone. Therefore, we may conclude that plating the fibula in a combined distal third tibia and fibula fracture does not enhance the stability of tibial IM nailing. The purpose of this study was to determine if combined distal third tibia and fibula fractures are more stable when fibular fixation is added to the standard tibial IM rodding. In combined distal third tibia and fibula fractures, plating the fibula does not enhance stability of intramedullary tibial nailing. No additional incision or soft tissue stripping is required for plating of the fractured fibula. The average range of motion in rotation was 19.1° for tibial and fibular fixation combined, and 18.0 ° for tibial fixation alone with a difference of 1.1°, which was clinically significant ( p=0.0034). The mean differences in vertical displacement, angulation, and neutral zone were not statistically significant. Five matched pairs of embalmed cadaveric lower limbs were dissected and stripped of soft tissue. Each tibia received a 9mm solid titanium nail that was locked proximally and distally. Fibular fixation consisted of a seven- hole LCDCP. A 1.5 cm section of tibia and a 1.0 cm section of fibula were removed. Testing was accomplished with an MTS machine. Vertical displacement was tested with an axial load to 500 N, rotation was tested with an internal and external torque of 5 Nm, and angulation was calculated from the vertical displacement data. All displacement data was measured across the osteotomy site. The mean range of motion in rotation was the only statistically significant finding. However, considering the average range of motion with and without fibular plating of 17.96° and 19.10° respectively, this finding is likely not clinically relevant. Funding: Tibial nails, bolts, fibular plates and screws provided by Synthes (Paoli, PA, USA)

Using human cadaver specimens, we investigated the role of supplementary fibular plating in the treatment of distal tibial fractures using an intramedullary nail. Fibular plating is thought to improve stability in these situations, but has been reported to have increased soft-tissue complications and to impair union of the fracture. We proposed that multidirectional locking screws provide adequate stability, making additional fibular plating unnecessary. A distal tibiofibular osteotomy model performed on matched fresh-frozen lower limb specimens was stabilised with reamed nails using conventional biplanar distal locking (CDL) or multidirectional distal locking (MDL) options with and without fibular plating. Rotational stiffness was assessed under a constant axial force of 150 N and a superimposed torque of ± 5 Nm. Total movement, and neutral zone and fracture gap movement were analysed.

In the CDL group, fibular plating improved stiffness at the tibial fracture site, albeit to a small degree (p = 0.013). In the MDL group additional fibular plating did not increase the stiffness. The MDL nail without fibular plating was significantly more stable than the CDL nail with an additional fibular plate (p = 0.008).

These findings suggest that additional fibular plating does not improve stability if a multidirectional distal locking intramedullary nail is used, and is therefore unnecessary if not needed to aid reduction.

Cite this article: Bone Joint J 2014;96-B:385–9.

The October 2023 Trauma Roundup. 360. looks at: Intramedullary nailing versus sliding hip screw in trochanteric fracture management: the INSITE randomized clinical trial; Five-year outcomes for patients with a displaced fracture of the distal tibia; Direct anterior versus anterolateral approach in hip joint hemiarthroplasty; Proximal humerus fractures: treat them all nonoperatively?; Tranexamic acid administration by prehospital personnel; Locked plating versus nailing for proximal tibia fractures: a multicentre randomized controlled trial; A retrospective review of the rate of septic knee arthritis after retrograde femoral nailing for traumatic femoral fractures at a single academic institution

Background. The use of a knotless TightRope for the stabilisation of a syndesmotic injury is a well-recognised mode of fixation. It has been described that the device can be inserted using a “closed” technique. This presents a risk of saphenous nerve entrapment and post-operative pain. Aim. We aimed to establish the actual risk of injury to the Saphenous Nerve using a “closed” technique for the insertion of a TightRope. Method. 20 TightRopes were inserted into Fresh Frozen Cadavers. This was done using the senior authors preferred technique of divergent tightropes with the distal implant directed slightly anterior to the fibula-tibia axis and the proximal implant slightly posterior in order to simulate the greatest risk to the nerve. This was done under image Intensifier guidance to simulate an intraoperative environment. The medial side of the distal tibia was then dissected to directly record and measure the relationship of the TightRope to the Saphenous Nerve. Measurements were taken using digital calipers from the centre of the button on the medial side of the TightRope to the centre of the nerve at the point of closest proximity. Results. 12 TightRopes were found to exit posterior to the nerve, 7 anterior and 1 penetrated through the centre of the nerve. The mean distance from the centre of the button to the nerve was 6.99mm (range 0.72–14.52mm, standard deviation 4.33mm). In 9 of the 20 TightRopes, the nerve was found to be less than 5mm away. Conclusion. Our findings demonstrated that the risks of damaging or indeed entrapping the Saphenous nerve were high, and therefore we would advocate an open incision on the medial side with judicious exploration to ensure there is no damage to the medial neurological structures

Introduction. Intra articular distal tibia fractures can lead to post-traumatic osteoarthritis. Joint distraction has shown promise in elective cases. However, its application in acute fractures remains unexplored. This pilot study aims to fill this knowledge gap by investigating the benefits of joint distraction in acute fractures. Materials & Methods. We undertook a restrospective cohort study comprising patients with intra-articular distal tibia and pilon fractures treated with a circular ring fixator (CRF) at a single center. Prospective data collection included radiological assessments, Patient-Reported Outcome Measures (PROM), necessity for additional procedures, and Kellgren and Lawrence grade (KL) for osteoarthritis (OA). 137 patients were included in the study, 30 in the distraction group and 107 in the non-distraction group. There was no significant difference between the groups. Results. Mean follow-up was 3.73 years. There was no significant difference between the groups in overall complications or need for further procedures. There was no significant difference in progression of KL between the groups (1.81 vs 2.0, p=0.38) mean follow up 1.90 years. PROM data was available for 44 patients (6 distraction, 38 non-distraction) with a mean follow-up of 1.71 years. There was no significant difference in EQ5D (p=0.32) and C Olerud-H Molander scores (p=0.17). Conclusions. This pilot study suggests that joint distraction is safe in the acute setting. However, the study's impact is constrained by a relatively small patient cohort and a short-term follow-up period. Future investigations should prioritise longer-term follow-ups and involve a larger patient population to more comprehensively evaluate the potential benefits of joint distraction in acute fractures

The incisura fibularis (IF) provides intrinsic stability to the ankle joint complex by interlocking the distal tibia and fibula. Despite a high frequency of ligamentous ankle injuries, scant attention has been given to the morphology of the IF morphology incisura fibularis in the onset and development of these lesions. Therefore, we systematically reviewed the relation between ligamentous ankle disorders and the morphometrics of the IF. A systematic literature search was conducted on following databases: PubMed, Embase and Web of Science. Search terms consisted of ‘ankle trauma’, ‘ankle injury’, ‘ankle sprain’, ‘ankle fracture’, ‘tibiofibular’, ‘fibular notch’, ‘fibular incisura’, ‘incisura fibularis’, ‘morphometric analysis’, ‘ankle syndesmosis’, ‘syndesmotic stability’. The evaluation instrument developed by Hawker et al. was used to assess the quality of the selected studies. This protocol was performed according to the PRISMA guidelines and is registered on PROSPERO (CRD42021282862). Nineteen studies were included and consisted of prospective cohort (n=1), retrospective comparative (n=10), and observational (n=8) study design. Comparative studies have found certain morphological characteristics in patients with ankle instability. Several studies (n=5) have correlated a shallow IF depth with a higher incidence of ankle injury. A significant difference has also been found concerning the incisura height and angle (n=3): a shorter incisura and more obtuse angle have been noted in patients with ankle sprains. The mean Hawker score was 28 out of 36 (range=24-31). A shallower IF is associated with ligamentous ankle lesions and might be due to a lower osseous resistance against tibiofibular displacement. However, these results should be interpreted in light of moderate methodological quality and should always be correlated with clinical findings. Further prospective studies are needed to further assess the relation between the incisura morphometrics and ligamentous disorders of the ankle joint. Keywords: ankle instability, ankle injury, incisura fibularis, fibular notch, tibiofibular morphometrics, ankle syndesmosis

Osteonecrosis is a potentially devastating condition with poorly defined pathogenesis that can affect several anatomical areas with or without a previous traumatic insult. Post traumatic osteonecrosis (PON) in the foot and ankle has been commonly described in the talus and navicular but rarely in the distal tibia. PON of the distal tibia is a rarely reported and infrequent complication of fracture dislocations of the ankle. Its scarcity can lead to misdiagnosis and inappropriate management due to a lack of clinical knowledge or suspicion with resultant severe functional compromise. We aim to highlight the clinical and radiological features of PON of the distal tibia and report the findings in a series of four patients following a fracture dislocation of the ankle. Three patients sustained a SER4 fracture dislocation and one patient sustained a PER4 fracture dislocation in keeping with standard patterns of injury seen in most trauma units. In each case, PON of the distal tibia presented with progressive anterolateral tibial plafond collapse and valgus deformity of the ankle. The radiological features previously reported in the literature are based on plain film x-ray, CT and MRI but no description of SPECT-CT findings. One of the patients in the series underwent SPECT-CT following clinical suspicion of PON and thus we describe the findings not previously reported. Our objective is to highlight this rare condition as a potential cause for ongoing pain following fracture dislocation of the ankle as well as advocating the use of SPECT/CT as a useful imaging modality to aid in the diagnosis

Abstract. Objectives. The syndesmosis joint, located between the tibia and fibula, is critical to maintaining the stability and function of the ankle joint. Damage to the ligaments that support this joint can lead to ankle instability, chronic pain, and a range of other debilitating conditions. Understanding the kinematics of a healthy joint is critical to better quantify the effects of instability and pathology. However, measuring this movement is challenging due to the anatomical structure of the syndesmosis joint. Biplane Video Xray (BVX) combined with Magnetic Resonance Imaging (MRI) allows direct measurement of the bones but the accuracy of this technique is unknown. The primary objective is to quantify this accuracy for measuring tibia and fibula bone poses by comparing with a gold standard implanted bead method. Methods. Written informed consent was given by one participant who had five tantalum beads implanted into their distal tibia and three into their distal fibula from a previous study. Three-dimensional (3D) models of the tibia and fibula were segmented (Simpleware Scan IP, Synopsis) from an MRI scan (Magnetom 3T Prisma, Siemens). The beads were segmented from a previous CT and co-registered with the MRI bone models to calculate their positions. BVX (125 FPS, 1.25ms pulse width) was recorded whilst the participant performed level gait across a raised platform. The beads were tracked, and the bone position of the tibia and fibula were calculated at each frame (DSX Suite, C-Motion Inc.). The beads were digitally removed from the X-rays (MATLAB, MathWorks) allowing for blinded image-registration of the MRI models to the radiographs. The mean difference and standard deviation (STD) between bead-generated and image-registered bone poses were calculated for all degrees of freedom (DOF) for both bones. Results. The absolute mean tibia and fibula bone position differences (Table 1) between the bead and BVX poses were found to be less than 0.5 mm for both bones. The bone rotation differences were found to be less than 1° for all axes except for the fibula Z axis rotation which was found to be 1.46°. One study. 1. has reported the kinematics of the syndesmosis joint and reported maximum ranges of motion of 9.3°and translations of 3.3mm for the fibula. The results show that the accuracy of the methodology is sufficient to quantify these small movements. Conclusions. BVX combined with MRI can be used to accurately measure the syndesmosis joint. Future work will look at quantifying the accuracy of the talus to provide further understanding of normal ankle kinematics and to quantify the kinematics across a healthy population to act as a comparator for future patient studies. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation. Materials & Methods. Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport. Results. Case 2 - A 12-year-old girl was referred with a three-month history of lateral left ankle swelling. X-ray demonstrated an aneurysmal bone cyst in the distal fibula metaphysis. The cyst grew from 4.2 × 2.3cm to 5.2 × 3.32cm in 2 months. A distal fibula resection (6.2cm) with syndesmosis fixation and hexapod cable transport frame were undertaken. The frame was in situ for 13 weeks and during this time she required an additional osteotomy for premature consolidation and had one pin site infection. After 13 weeks a second syndesmosis screw was placed, frame removed, and a cast applied. 3 months later she had fibular plating, BMAC and autologous iliac crest bone graft for slow union. At 3 years post-operative she has no evidence of recurrence, is pain-free and has no functional limitation. Conclusions. We describe two cases of ankle syndesmosis preservation using cable transport for juxta-articular aneurysmal bone cysts. This allows wide resection to prevent recurrence while also preserving primary ankle stability and leg length in children. Both children had a minor complication, but both had an excellent final outcome. Cable bone transport and prophylactic syndesmosis stabilization allows treatment of challenging juxta-articular aneurysmal bone cysts about the ankle. These techniques are especially useful in large bone defects

Abstract. Objectives. Epiphysiodesis is a commonly used treatment for lower limb angular deformities. However, in recent years, distal tibial growth modulation using ‘eight plates’ or screws has emerged as an alternative treatment for paediatric foot and ankle disorders, such as CTEV. Our objective was to assess the efficacy of distal tibial modulation in correcting various paediatric foot and ankle disorders. Methods. This retrospective study analysed 205 cases of paediatric foot and ankle disorders treated between 2003 and 2022, including only cases where the eight plate or screw was fixed on the anterior surface of the distal tibia. Our aim was to measure post-operative changes in dorsiflexion, the distal tibial angle, and the tibiocalcaneal angle by examining clinical records and radiology reports. Results. We identified nine cases (nine feet) meeting the full inclusion criteria, comprising seven cases of CTEV, one case of arthrogryposis, and one case of cavovarus foot. The cohort consisted of five male and four female patients, with a mean age of 10 years and 9 months at the time of surgery. Seven cases involved the left tibia, and two cases involved the right tibia. The mean time between pre-operative X-ray to surgery was 168 days, and the mean turnaround time between surgery and post-operative X-ray was 588 days. A mean change in the distal tibial angle of 4.33 degrees was noted. However, changes in dorsiflexion were documented in only one case, which showed a change of 13 degrees. Notably, our average distal tibial angle was significantly lower than reported in the literature, at 4.33 degrees. Additionally, some studies in the literature used the Oxford Ankle Foot Questionnaire for Children to assess pre- and post-operative outcomes, but it is important to note that it is validated only for children aged 5 to 16. Furthermore, most cases reported an improved tibiocalcaneal angle except for an anomaly of 105 degrees. We assessed satisfactory patient outcomes using patient notes. Out of the 6 procured notes, one has been discharged. The rest are still under yearly or 6-monthly review and are at various stages, such as physiotherapy, removing the eight plate, or requiring further surgery. The most common presentations at review are plantaris deformity and pain. Conclusions. Our study suggests that distal tibial growth modulation can be an effective treatment option for selected paediatric foot and ankle disorders. However, due to the limited number of cases in our study, the lack of documentation of changes in dorsiflexion, and a lack of pre- and post-operative outcomes using a standardised method, further research is needed to investigate this procedure's long-term outcomes and potential complications. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

We have assessed the proximal capsular extension of the ankle joint in 18 patients who had a contrast-enhanced MRI ankle arthrogram in order to delineate the capsular attachments. We noted consistent proximal capsular extensions anterior to the distal tibia and in the tibiofibular recess. The mean capsular extension anterior to the distal tibia was 9.6 mm (4.9 to 27.0) proximal to the anteroinferior tibial margin and 3.8 mm (−2.1 to 9.3) proximal to the dome of the tibial plafond. In the tibiofibular recess, the mean capsular extension was 19.2 mm (12.7 to 38.0) proximal to the anteroinferior tibial margin and 13.4 mm (5.8 to 20.5) proximal to the dome of the tibial plafond. These areas of proximal capsular extensions run the risk of being traversed during the insertion of finewires for the treatment of fractures of the distal tibia. Surgeons using these techniques should be aware of this anatomy in order to minimise the risk of septic arthritis

Introduction and Objective. Forced external rotation is hypothesized as the key mechanism of syndesmotic ankle injuries. This complex trauma pattern ruptures the syndesmotic ligaments and induces a three-dimensional deviation from the normal distal tibiofibular joint configuration. However, current diagnostic imaging modalities are impeded by a two-dimensional assessment, without taking into account ligamentous stabilizers. Therefore, our aim is two-fold: (1) to construct an articulated statistical shape model of the normal ankle with inclusion of ligamentous morphometry and (2) to apply this model in the assessment of a clinical cohort of patients with syndesmotic ankle injuries. Materials and Methods. Three-dimensional models of the distal tibiofibular joint were analyzed in asymptomatic controls (N= 76; Mean age 63 +/− 19 years), patients with syndesmotic ankle injury (N = 13; Mean age 35 +/− 15 years), and their healthy contralateral equivalent (N = 13). Subsequently, the statistical shape model was generated after aligning all ankles based on the distal tibia. The position of the syndesmotic ligaments was predicted based on previously validated iterative shortest path calculation methodology. Evaluation of the model was described by means of accuracy, compactness and generalization. Canonical Correlation Analysis was performed to assess the influence of syndesmotic lesions on the distal tibiofibular joint congruency. Results. Our presented model contained an accuracy of 0.23 +/− 0.028 mm. Mean prediction accuracy of ligament insertions was 0.53 +/− 12 mm. A statistically significant difference in anterior syndesmotic distance was found between ankles with syndesmotic lesions and healthy controls (95% CI [0.32, 3.29], p = 0.017). There was a significant correlation between presence of syndesmotic injury and the morphological distal tibiofibular configuration (r = 0.873, p <0,001). Conclusions. In this study, we constructed a bony and ligamentous statistical model representing the distal tibiofibular joint Furthermore, the presented model was able to detect an elongation injury of the anterior inferior tibiofibular ligament after traumatic syndesmotic lesions in a clinical patient cohort

Introduction/Purpose. Total ankle replacement (TAR) success has improved since first-generation implants, but patient satisfaction continues to be less than knee and hip replacements. Little is known about variations in distal tibia anatomy between genders and across ethnicities; therefore it is unclear the extent to which current TAR prostheses accommodate variability in patient size and shape. This study quantified distal tibia morphometrics relevant to TAR design, and assessed differences between ethnicities and genders. The hypotheses were: (1) The anterior-posterior (AP) location of the dwell point of the tibia is centralized; (2) The sagittal radius of curvature of the tibial articulation increases with bone size; (3) Differences in dwell point location or sagittal radii between genders and ethnicities can be attributed to size differences between those populations. Methods. Tibial CT scans were obtained from cadavers or individuals of various ethnicities (Table 1). Landmarks were defined on digital models created from the scans, including medial and lateral edges of the distal tibial articulation (Figure 1a), and sagittal contours of the articulation (Figure 1b). The articulation center was defined as the average center point of all contours (Figure 1c). The AP center and AP length at the level of a distal tibial resection for TAR were determined, and the AP offset of the articulation center was calculated (Figure 1c). Differences in metrics for each ethnic and gender group were determined using a one-way Anova (P<.05) with Tukey's method for differentiating groups. Regression fits of AP offset, average medial radius, and average lateral radius were determined. Utilizing AP length as a covariate, ANCOVA was utilized to assess differences in AP offset and sagittal radii between gender and ethnic groups (P<.05). Results. Descriptive statistics for AP length, AP offset, and medial/lateral radii are shown in Table 1, with Tukey groupings assigned. The relationship between medial and lateral radius was not consistent across all groups. AP length was a significant covariate for medial and lateral radii, but not AP offset. The relationship between lateral radius and AP length was significantly impacted by ethnicity (P<.001), but not by gender (P=.067) (Figure 2a). Medial radius versus AP length was significantly impacted by both ethnicity (P=.01) and gender (P<.03) (Figure 2b). Conclusion. This study illustrates for the first time the complexity of anatomical variation of the distal tibia across ethnic groups and between genders. The location of the articulation center is invariant to tibia size across each ethnicity. Medial and lateral sagittal radii generally increase with bone size, but the relative radii of the medial and lateral compartments are not consistent across ethnicities. These results highlight the need for increased anatomic understanding of the distal tibia, and implications on TAR design and technique

Introduction. Pilon fractures are complex, high-energy, intra-articular fractures of the distal tibia. Achieving good outcomes is challenging due to fracture complexity and extensive soft tissue damage. The purpose of this study was to determine the long-term functional and clinical outcomes of definitive management with fine wire Ilizarov fixation for closed pilon fractures. Materials and Methods. 185 patients treated over a 14-year period (2004–2018) were included. All patients had Ilizarov frames applied to restore mechanical axis and fine wires to control periarticular fragments. CT scans were performed post operatively to confirm satisfactory restoration of the articular surface. All frames were dynamized prior to removal. Patients' functional outcome was assessed using the validated Chertsey Outcome Score for Trauma (“COST”). Review of clinical notes and imaging was used to determine complications and time to union. Results. The mean functional outcome in the studied cohort was determined to be “average” on the “COST” score. Poorer functional outcomes were associated with younger age at time of injury and multi-fragment fracture patterns. Mean time in frame was 170 days. Complication rates were low. There were no deep infections, no amputations and only 8 patients went on to have ankle fusions. Conclusions. Good functional results and low complication rates can be achieved by managing pilon fractures with fine wire Ilizarov fixation. Nonetheless, at time of injury patients should be counselled as to the severity of the injury and impact on their functional status

Purpose. Alpine skiing is associated with large skeletal loads with distinct patterns of loading rate and direction, and alpine skiers were previously found to have a robust bone structure compared to normally active controls. However, it is not known whether the mechanical stimuli experienced by skiers are also associated with enhanced bone microarchitecture and strength. Thus, the purpose of this study was to use high-resolution peripheral quantitative computed tomography (HR-pQCT) to compare bone macro- and microarchitecture and bone strength between elite alpine skiers and normally active controls. Method. Participants included 7 female and 12 male members of the Canadian Alpine Ski Team, and 10 female and 16 male normally active control subjects. A whole body dual energy X-ray absorptiometry (DXA) scan was performed to measure lean mass and percent body fat. HR-pQCT (XtremeCT, Scanco) was used to assess bone macro- and microarchitecture including total, cortical and trabecular bone area, total and cortical bone mineral density (BMD), and bone volume ratio (BV/TV) of the dominant distal tibia and radius. Finite element analysis was applied to the HR-pQCT scans to estimate bone strength (failure load, N). Analysis of covariance (ANCOVA) was used to compare outcomes between groups adjusting for body weight (tibia) and height (tibia and radius). Results. Bone area of the distal radius was significantly greater in female (30%, p<.001) and male (21%, p=.003) skiers compared with controls. Similarly, distal radius failure load was greater in female (37%, p=.001) and male (42%, p<.001) skiers. Higher BV/TV was apparent in the distal tibia of the male (18%, p=.005) and female skiers (19%, p=.012) and at the radius for the male skiers (19%, p=.02) compared with controls. High BV/TV is associated with a higher trabecular area at the distal tibia for the female athletes (14%, p=.06) and the distal radius for male athletes (32%, p=.002). Distal tibia failure load was higher in male (18%, p<.001) and female skiers (22%, p=.012) compared with controls. Distal tibia failure load remained significantly higher for the male athletes even after adjusting for lean mass. Conclusion. Compared to controls, skiers have larger bone areas at the radius in men and women, and at the tibia in women. Trabecular bone volume is augmented in skiers compared with controls, even after adjusting for height and weight. After adjusting for lean mass, group differences in bone strength were still apparent at the distal tibia in men, suggesting that direct mechanical input associated with alpine skiing affects bone microarchitecture. In conclusion a larger bone size and greater trabecular bone volume may represent skeletal adaptations to the extreme mechanical environment experienced during competitive skiing, and likely contribute to the greater bone strength observed in skiers compared with controls at both skeletal sites

Introduction and Objective. Intramedullary nails are frequently used for treatment of unstable distal tibia fractures. However, insufficient fixation of the distal fragment could result in delayed healing, malunion or nonunion. The quality of fixation may be adversely affected by the design of both the nail and locking screws, as well as by the fracture pattern and bone density. Recently, a novel concept for angular stable nailing has been developed that maintains the principle of relative stability and introduces improvements expected to reduce nail toggling, screw migration and secondary loss of reduction. It incorporates polyether ether ketone (PEEK) inlays integrated in the distal and proximal canal portions of the nail for angular stable screw locking. The nail can be used with new standard locking screws and low-profile retaining locking screws, both designed to enhance cortical fixation. The low-profile screws are with threaded head, anchoring in the bone and increasing the surface contact area due to the head's increased diameter. The objective of this study was to investigate the biomechanical competence of the novel angular stable intramedullary nail concept for treatment of unstable distal tibia fractures, compared with four other nail designs in an artificial bone model under dynamic loading. Materials and Methods. The distal 70 mm of thirty artificial tibiae (Synbone) were assigned to 5 groups for distal locking using either four different commercially available nails – group 1: Expert Tibia Nail (DePuy Synthes); group 2: TRIGEN META-NAIL with Internal Hex Captured Screws (Smith & Nephew); group 3: T2 Alpha with Locking Screws (Stryker); group 4: Natural Nail System featuring StabiliZe Technology (Zimmer) – or the novel angular stable TN-Advanced nail with low-profile screws (group 5, DePuy Synthes). The distal locking in all groups was performed using 2 mediolateral screws. All specimens were biomechanically tested under quasi-static and progressively increasing combined cyclic axial and torsional loading in internal rotation until failure, with monitoring by means of motion tracking. Results. Initial nail toggling of the distal tibia fragment in group 5 was significantly lower as compared with group 3 in varus (p=0.04) or with groups 2 and 4 in flexion (p≤0.02). In addition, the toggling in varus was significantly lower in group 1 versus group 4 (p<0.01). Moreover, during dynamic loading, within the course of the first 10,000 cycles the movements of the distal fragment in terms of varus, flexion, internal rotation, as well as axial and shear displacements at the fracture site, were all significantly lower in group 5 compared with group 4 (p<0.01). Additionally, group 5 demonstrated significantly lower values for flexion versus groups 2 and 3 (p≤0.04), for internal rotation versus group 1 (p=0.03), and for axial displacement versus group 3 (p=0.03). A trend to significantly lower values was detected in group 5 versus group 1 for varus, flexion and shear displacement – with p ranging between 0.05 and 0.07 – and versus group 3 for shear displacement (p=0.07). Cycles to failure were highest in group 5 with a significant difference to group 4 (p<0.01). Conclusions. From a biomechanical perspective, the novel angular stable intramedullary nail concept with integrated PEEK inlays and low-profile screws provides ameliorated resistance against nail toggling and loss of reduction under static and dynamic loading compared with other commercially available intramedullary nails used for fixation of unstable distal tibia fractures

Objectives. Overlap between the distal tibia and fibula has always been quoted to be positive. If the value is not positive then an injury to the syndesmosis is thought to exist. Our null hypothesis is that it is a normal variant in the adult population. Methods. We looked at axial CT scans of the ankle in 325 patients for the presence of overlap between the distal tibia and fibula. Where we thought this was possible we reconstructed the images to represent a plain film radiograph which we were able to rotate and view in multiple planes to confirm the assessment. . Results. The scans were taken for reasons other than pathology of the ankle. We found there was no overlap in four patients. These patients were then questioned about previous injury, trauma, surgery or pain, in order to exclude underlying pathology. Conclusion. We concluded that no overlap between the tibia and fibula may exist in the population, albeit in a very small proportion

Introduction. Fractures of the distal tibia can be challenging to manage. Numerous surgical techniques have been utilised in managing these however there remains debate as to the optimum method of fixation. This study aims to assess the surgical outcomes and PROMs of patients with distal tibial fractures managed with intramedullary-nails or ring fixation. Methods. This is a retrospective study of patients with closed distal tibial fractures managed between 01/01/2013–31/12/2016. Adult patients admitted with closed fracture of the distal tibia fixed with an intramedullary-nail or circular-frame were included in the study. Primary outcomes were time of union, alignment of tibia post-operatively and the results of two validated PROMs (Kujala knee score and Olerud and Molander Ankle Score). Results. 12 patients had circular-frame and 14 patients underwent intramedullary-nailing. PROMS were completed in 9 (75%) of the frame group and 7 (50%) of the nail group. There was no statistically significant difference in age (p=0.095); no statistically significant difference in time to union (medians = frame 29.7 weeks, IM nail 24 weeks, p=0.212); no statistically significant difference in the coronal angulation difference from neutral (medians = frame 1.9 degrees, IM nail 2.0 degrees, p=0.940). There was statistically significant difference in sagittal angulation difference from neutral (Medians = frame 3 degrees, IM nail 0.6 degrees, p=0.041); the proportion of males in the frames groups was statistically significantly higher (p=0.033). There was no statistically significant difference in outcome of ankle scores (medians = frame 92.5, IM nail 75, p=0.132); there was a statistically significant difference in the knee score favouring the frame group (medians = frame 99, IM nail 74.5, p=0.041). Discussion. Our results show distal tibia fractures can be treated with circular-frames or IM-nails. Patients at high-risk of soft tissue complication or to minimise the risk of knee symptoms should be considered for a circular-frame

Aims. There is little information about how to manage patients with a recurvatum deformity of the distal tibia and osteoarthritis (OA) of the ankle. The aim of this study was to evaluate the functional and radiological outcome of addressing this deformity using a flexion osteotomy and to assess the progression of OA after this procedure. Patients and Methods. A total of 39 patients (12 women, 27 men; mean age 47 years (28 to 72)) with a distal tibial recurvatum deformity were treated with a flexion osteotomy, between 2010 and 2015. Nine patients (23%) subsequently required conversion to either a total ankle arthroplasty (seven) or an arthrodesis (two) after a mean of 21 months (9 to 36). A total of 30 patients (77%), with a mean follow-up of 30 months (24 to 76), remained for further evaluation. Functional outcome, sagittal ankle joint OA using a modified Kellgren and Lawrence Score, tibial lateral surface (TLS) angle, and talar offset ratio (TOR) were evaluated on pre- and postoperative weight-bearing radiographs. Results. Postoperatively, the mean score for pain, using a visual analogue scale, decreased significantly from 4.3 to 2.5 points and the mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly from 59 to 75 points (both p < 0.001). The mean TLS angle increased significantly by 6.6°; the mean TOR decreased significantly by 0.24 (p < 0.001). Radiological evaluation showed an improvement or no progression of sagittal ankle joint OA in 32 ankles (82%), while seven ankles (18%) showed further progression. Conclusion. A flexion osteotomy effectively improved the congruency of the ankle joint. In 30 patients (77%), the joint could be saved, whereas in nine patients (23%), the treatment delayed a joint-sacrificing procedure. Cite this article: Bone Joint J 2019;101-B:682–690

Autologous bone has been the gold standard for grafting material in foot and ankle arthrodesis. While autograft use has been effective, the harvest procedure does present risks to the patient including readmission, infection, and persistent graft harvest site pain. Previous studies have examined graft harvest site pain, but most have focused on the iliac crest and none have long term follow-up. The purpose of this study was to examine long-term (7–10 year) harvest site pain in subjects undergoing autograft harvest from multiple sites for hindfoot and/or ankle arthrodesis. Sixty (60) subjects underwent hindfoot or ankle arthrodesis supplemented with autograft as part of the control arm of a prospective, randomized trial. The mean subject age was 59.4 years (range, 24.7–76.8) and mean body mass index was 30.6 kg/m2 (range, 22.0–44.0). There were 29 males and 31 female subjects. Subjects had the tibiotalar (37.9%), subtalar (24.1%), talonavicular (10.3%), subtalar/talonavicular (5.1%), or subtalar/calcaneocuboid/talonavicular (22.4%) joints arthrodesed. Autograft was harvested from either the proximal tibia (51.7%), iliac crest (17.2%), calcaneous (15.5%), distal tibia (6.8%), or other location (8.6%). Graft harvest site pain was evaluated using a 100-point visual analog score (VAS), with clinically significant pain being any score greater than 20. Subjects were followed a mean of 9.0 years (range, 7.8–10.5). The percentage of subjects who reported clinically significant pain was 35.7%, 21.4%, 18.2%, 10.5%, 8.9%, and 5.2% at 2, 6, 12, 24, 52 weeks, and final follow-up (7.8–10.5 years), respectively. The mean VAS autograft harvest site pain at final follow-up was 4.4 (range, 0.0–97.0), with 37.9% of subjects reporting at least some pain. For three subjects (5%) with clinically significant pain (VAS >20) at final follow-up, two had proximal tibial harvest sites and one had an iliac crest harvest site. There was no correlation between graft volume and harvest site pain. This study is the first to examine long-term pain following autologous bone graft harvest for hindfoot and/or ankle arthrodesis. Over a third of patients reported having some pain at an average follow-up of nine years, with 5% experiencing clinically significant pain. The results of this study suggest that harvesting autograft bone carries a risk of persistent, long-term pain regardless of the volume of graft that is harvested. This potential for persistent pain should be considered when informing patients of procedure risks and when deciding to use autograft or a bone graft substitute material

Unstable distal tibia fractures are challenging injuries requiring surgical treatment. Intramedullary nails are frequently used; however, distal fragment fixation problems may arise, leading to delayed healing, malunion or nonunion. Recently, a novel angle-stable locking nail design has been developed that maintains the principle of relative construct stability, but introduces improvements expected to reduce nail toggling, screw migration and secondary loss of reduction, without the requirement for additional intraoperative procedures. The aim of this study was to investigate the biomechanical competence of a novel angle-stable intramedullary nail concept for treatment of unstable distal tibia fractures, compared to a conventional nail in a human cadaveric model under dynamic loading. Ten pairs of fresh-frozen human cadaveric tibiae with a simulated AO/OTA 42-A3.1 fracture were assigned to 2 groups for reamed intramedullary nailing using either a conventional (non-angle-stable) Expert Tibia Nail with 3 distal screws (Group 1) or the novel Tibia Nail Advanced system with 2 distal angle-stable locking low-profile screws (Group 2). The specimens were biomechanically tested under conditions including quasi-static and progressively increasing combined cyclic axial and torsional loading in internal rotation until failure of the bone-implant construct, with monitoring by means of motion tracking. Initial axial construct stiffness, although being higher in Group 2, did not significantly differ between the 2 nail systems, p=0.29. In contrast, initial torsional construct stiffness was significantly higher in Group 2 compared to Group 1, p=0.04. Initial nail toggling of the distal tibia fragment in varus and flexion was lower in Group 2 compared to Group 1, being significant in flexion, p=0.91 and p=0.03, respectively. After 5000 cycles, interfragmentary movements in terms of varus, flexion, internal rotation, axial displacement and shear displacement at the fracture site were all lower in Group 2 compared to Group 1, with flexion and shear displacement being significant, p=0.14, p=0.04, p=0.25, p=0.11 and p=0.04, respectively. Cycles to failure until both interfragmentary 5° varus and 5° flexion were significantly higher in Group 2 compared to Group 1, p=0.04. From a biomechanical perspective, the novel angle-stable intramedullary nail concept has the potential of achieving a higher initial axial and torsional relative stability and maintaining it with a better resistance towards loss of reduction under dynamic loading, while reducing the number of distal locking screws, compared to conventional locking in intramedullary nailed unstable distal tibia fractures

Background: The results of arthroscopic anterior labral (Bankart) repair have been shown to have high failure rate in patients with significant glenoid bone loss. Several reconstruction procedures using bone graft have been described to overcome the bone loss, including autogenous coracoid transfer to the anterior glenoid (Latarjet procedure) as well as iliac crest autograft and tibial allografts. In recent years, trends toward minimally invasive shoulder surgery along with improvements in technology and technique have led surgeons to expand the application of arthroscopic treatment. Purpose: This study aims to perform a retrospective analysis of prospectively collected data to evaluate the clinical and radiological follow up of patient who underwent anatomic glenoid reconstruction using distal tibia allograft for the treatment of shoulder instability with glenoid bone loss at 1-year post operation time point. Between December 2011 and January 2015, 55 patients underwent arthroscopic stabilisation of the shoulder by means of capsule-labral reattachment to glenoid ream and bony augmentation of glenoid bone loss with distal tibial allograft for recurrent instability of the shoulder. Preoperative and postoperative evaluation included general assessment by the western Ontario shoulder instability index (WOSI) questionnaire, preoperative and postoperative radiographs and CT scans. Fifty-five patients have been evaluated with mean age of 29.73 years at time of the index operation. There were 40 males (mean age of 29.66) and 15 female (mean age of 29.93). Minimum follow up time was 12 months. The following adverse effects were recorded: none suffered from recurrent dislocation, 2 patients suffered from bone resorption but without overt instability, 1 patient had malunion due to screw fracture, None of the patients had nonunion. The mean pre-operative WOSI score was 36.54 and the mean postoperative WOSI score was 61.0. Arthroscopic stabilisation of the shoulder with distal tibia allograft augmentation demonstrates promising result at 1year follow up

The traditional techniques involving an oblique tunnel or triangular wedge resection to approach a central or mixed-type physeal bar are hindered by poor visualisation of the bar. This may be overcome by a complete transverse osteotomy at the metaphysis near the growth plate or a direct vertical approach to the bar. Ilizarov external fixation using small wires allows firm fixation of the short physis-bearing fragment, and can also correct an associated angular deformity and permit limb lengthening. . We accurately approached and successfully excised ten central- or mixed-type bars; six in the distal femur, two in the proximal tibia and two in the distal tibia, without damaging the uninvolved physis, and corrected the associated angular deformity and leg-length discrepancy. Callus formation was slightly delayed because of periosteal elevation and stretching during resection of the bar. The resultant resection of the bar was satisfactory in seven patients and fair in three as assessed using a by a modified Williamson–Staheli classification. Cite this article: Bone Joint J 2015;97-B:1726–31

Purpose: We report the clinical and functional outcome of limb salvage surgery and endoprosthetic reconstruction of the distal tibia and ankle joint in 5 patients. Introduction: The distal tibia is an uncommon site for primary malignant bone tumours and the treatment of choice for most patients is a below knee amputation. Patients who decline an amputation may be offered an endoprosthetic replacement. This is a technically challenging operation and may be associated with high morbidity. Methods and Results: Over 25 years at our centre, 5 patients underwent distal tibial replacements for bone or soft tissue sarcomas. Two had osteosarcoma, one had a recurrence of Ewing’s sarcoma, one had malignant fibrous histiocytoma, and one had an adamantinoma. The mean age was 37 years (13 to 69 years). There were no tumour recurrences. Four patients developed complications with wound infection. Two of these resulted in below knee amputations. Average follow-up was 31 months (19 to 55 months) with 1 patient lost to follow-up. Patients were evaluated using the Toronto Extremity Salvage Score (TESS) and the Musculoskeletal Tumour Society (MSTS) score. The mean MSTS score was 88% and the mean TESS was 88.5%. Two patients who later had a below knee amputation and who were using a prosthesis averaged an MSTS score of 86.3% and a TESS of 89.3%. Conclusion: For those patients who are unwilling to undergo an amputation for malignant tumours of the distal tibia, endoprosthetic reconstruction is an alternative, but at the cost of increased risk of significant complications, functional deterioration and morbidity. There was little difference between functional scores for patients who proceeded to have a below knee amputation compared to patients who still had their endoprosthesis

Purpose. Stress fractures (SFs) are highly prevalent in female athletes, especially runners (1337%), and result in pain and lost training time. There are numerous risk factors for SFs in athletes; however, the role of bone quality in the etiology of SFs is currently unknown. Therefore, our primary objective was to examine whether there are characteristic differences in bone quality and bone strength in female athletes with lower limb SFs using high-resolution peripheral quantitative computed tomography (HR-pQCT). A secondary objective was to compare muscle strength between SF subjects and controls. Method. Female athletes with (n=19) and without (n=19) lower limb SFs were recruited from the local community. All SFs were medically confirmed by a physician and subjects were assessed within 1–47 weeks (12.7 13.7) of diagnosis. Controls were age-, training volume- and sport-matched to SF athletes. Bone density and microarchitectural bone parameters such as cortical thickness and porosity, as well as trabecular thickness, separation and number of all subjects were assessed using HR-pQCT at two distal tibia scanning sites (distal, ultra-distal). Finite element (FE) analysis was employed to estimate bone strength and load sharing of cortical and trabecular bone from the HR-pQCT scans. Regional analysis was applied to the HR-pQCT scans to investigate site-specific bone differences between groups. Muscle torque was measured by a Biodex dynamometer as a surrogate of muscle strength. Independent sample t-tests and Mann-Whitney U-tests were used for statistical analyses (p < 0.05). Results. Significant differences and trends indicated compromised trabecular bone and slightly thicker cortices with fewer pores in SF subjects compared with controls. This was most pronounced in the posterior region of the distal tibia, which is the site of highest tensile stresses during running and a common SF site. FE analysis indicated significantly higher cortical loads (median 4.2% higher; p=0.03) in the distal tibia site (but not ultra-distal site) of SF subjects compared to controls. The SF group exhibited significantly reduced knee extension strength (median 18.3% lower; p=0.03) and a trend towards reduced plantarflexion (median 17.3% lower; p=0.24) and eversion strength (median 9.6% lower; p=0.49) compared to controls. Conclusion. This is the first study to compare bone microarchitectural quality and lower-limb muscle strength between female athletes with SFs and health controls. A reduced trabecular bone quality in SF subjects may result in an insufficient ability to absorb and distribute tibial loads. This, in turn, may lead to higher stresses in the cortex and a higher risk for SFs. Low muscle strength may increase SF risk by providing insufficient muscular support to counteract shear stresses associated with reaction forces during running. Further study is needed to determine whether a resistance-training program can improve bone quality and in turn, reduce SF risk

Aim. Post traumatic distal tibia osteomyelitis (DTOM) with an upper ankle joint involvement is a serious complication after primary osteosynthesis and can be a nightmare for the patient and the surgeon as well. Our aim was to identify mayor complications during treatment and to find the way to prevent or treat them. Method. It is a retrospective analysis of eight patients with DTOM and an upper ankle joint involvement treated in our institution from 2012 to 2018. The average size of a bone defect after a debridement was 9 centimeters (4–15). Patients were treated in two stages. First stage was segmental bone resection, external fixation and soft tissue envelope reconstruction if necessary. At second stage a distraction frame was applied and proximal corticotomy performed. In all but one case a circular frame was used. Results. We have had one major intra-operative complication, an injury of arteria tibialis posterior during the corticotomy procedure. Except in one patient we did not observe major problems with pin-track infections. Despite bone-grafting in all patients, we observed three nonunions of docking site. We treated them by external fixator in two and retrograde intramedullar nail in one case. In two patient the distraction callus was weak. We had to bone graft and secure the callus with a plate in one and use a retrograde reamed intramedullar nail in second patient. We have observed two callus fracture after removal of the frame. A surgery was needed for both because of the deformation. The first patient was treated by new external frame, the second by retrograde reamed intramedullar nail. Conclusions. Callus distraction is a valuable option to treat a bone defect. The procedure has many possible problems and complications, especially during treatment of defects larger than six centimeters. It is very difficult for patients to tolerate a frame more than one year. We have found the use of an intramedullar tibial nail inserted in a retrograde way as a helpful option not just to shorten the time of external frame, but in combination with reaming also to accelerate the healing of the distraction callus and the upper ankle joint arthrodesis as well

Introduction. Intramedullary nailing is gaining popularity for treatment of distal tibial fractures due to short operative time and minimum surgical trauma to soft tissues. Distal tibial fractures are commonly associated with concurrent fibular fractures at, above or below the level of tibial fractures. So far there is no consensus for fixation of fibular fractures. Materials and Methods. Fractures of fibula at or below the level of fracture of tibia were taken into consideration. Fractures of fibula above the tibial level were excluded because they do not add to stability of fracture fixation. Retrospective study was done and distal tibia-fibula fractures were separated into 2 groups based on whether fibula was fixed or not. Measures of angulation were obtained from radiographs taken immediately after the surgery, a second time 3 months later, and at 6-month follow-up. Results. 35 fracture of distal tibia and fibula were included in study. Fibula was not fixed in 21 cases while 14 fibular fixations were carried out either using short plates(8) or intramedullary pins(6). No significant differences were observed for malalignment in fracture of fibula at the level of tibial fractures. However for fractures of fibula at a level lower than its tibial counterpart, fixation of fibula significantly reduced malalignment. Conclusion. Fixation of fibula has a definite role in reducing malunion in cases where fibula was fractured below the level of tibial fracture. Fixation of fibula may increase overall stability of fixation of tibia and reduce malunion

A new method of vascularised tibial grafting has been developed for the treatment of avascular necrosis (AVN) of the talus and secondary osteoarthritis (OA) of the ankle. We used 40 cadavers to identify the vascular anatomy of the distal tibia in order to establish how to elevate a vascularised tibial graft safely. Between 2008 and 2012, eight patients (three male, five female, mean age 50 years; 26 to 68) with isolated AVN of the talus and 12 patients (four male, eight female, mean age 58 years; 23 to 76) with secondary OA underwent vascularised bone grafting from the distal tibia either to revascularise the talus or for arthrodesis. The radiological and clinical outcomes were evaluated at a mean follow-up of 31 months (24 to 62). The peri-malleolar arterial arch was confirmed in the cadaveric study. A vascularised bone graft could be elevated safely using the peri-malleolar pedicle. The clinical outcomes for the group with AVN of the talus assessed with the mean Mazur ankle grading scores, improved significantly from 39 points (21 to 48) pre-operatively to 81 points (73 to 90) at the final follow-up (p = 0.01). In all eight revascularisations, bone healing was obtained without progression to talar collapse, and union was established in 11 of 12 vascularised arthrodeses at a mean follow-up of 34 months (24 to 58). MRI showed revascularisation of the talus in all patients. . We conclude that a vascularised tibial graft can be used both for revascularisation of the talus and for the arthrodesis of the ankle in patients with OA secondary to AVN of the talus. Cite this article: Bone Joint J 2015; 97-B:802–8

The purpose of this study was to obtain anatomical measurements of the distal tibia and talus of Korean ankles and to evaluate, based on those measurements, the compatibility of the HINTEGRA prostheses in the context of total ankle replacement (TAR). We measured the length, width, height, and angles of the distal tibia and talus of 51 cadavers and compared these measurements with the corresponding dimensions of the HINTEGRA prostheses. The male ankles were larger than the female ones as was expected, but their overall shapes did not differ, which fact validates use of the prostheses irrespective of patients' sex. The dimensions of the talus itself did not differ significantly from those previously reported for American whites and blacks and South African whites. This might suggest a possibility that the HINTEGRA prostheses, being used in these countries, would be compatible to Korean ankles, too. In fact, the length range of the talar components was generally compatible with those derived from cadaveric measurements of the trochlea. However, the widths of the tibial and talar components were not completely compatible to Korean ankles. Above all, the length of the large-sized tibial components was much longer than the largest ankles, which would confine the choice of prosthesis mainly to small-sized ones for arthroplasty in Korea. Even though these prostheses are currently used, some modifications are needed to extend their usability in Korea, such as shortening and width/length ratio adjustment of the tibial component, and of the talar component accordingly

Aims

Triplane ankle fractures are complex injuries typically occurring in children aged between 12 and 15 years. Classic teaching that closure of the physis dictates the overall fracture pattern, based on studies in the 1960s, has not been challenged. The aim of this paper is to analyze whether these injuries correlate with the advancing closure of the physis with age.

Cutting rodent's bone ends and irrigation of the medullary canal is the common method used for cells collection in allogenic transplantation, however it does not yield sufficient cells for autologous transplantation. The aim of this experiment was to establish and validate a method for bone marrow collection for autologous MSCs transplantation. Two collection methods were examined: 1) Transection of the bone ends and irrigation of the medullary canal, 2) Trephining of the bone with a hypodermic needle without aspiration. Then cell harvesting was compared in the idealised laboratory situation and under simulated surgery. First, two lower limbs were harvested from the same rat cadaver for comparison, bone marrow in one limb was collected by cutting the femoral head and the distal tibia and irrigation of the canal through drilled holes at the distal end of the femur and proximal end of the tibia. Other limb, hypodermic needle was used as a trephining tool into the medullary canal multiple times without applying negative pressure and rinsed from inside and outside. Second, bone marrow was harvested from another rat's cadaver in the surgery room to simulate the conditions needed for autologous transplantation. The number of cells from irrigation method was 1.28*106 cells, whereas that from trephining method reached 17*106. The number cells from the bone marrow harvested in the surgery room was found 29.6*106. We report a novel technique for harvesting cells for autologous cell therapy from only one limb. A significantly larger number of cells from bone marrow could be collected using the needle trephining method. There is no negative effect on the viability of cells after bone marrow harvesting in the surgery room

Aims

Total knee arthroplasty (TKA) may provoke ankle symptoms. The aim of this study was to validate the impact of the preoperative mechanical tibiofemoral angle (mTFA), the talar tilt (TT) on ankle symptoms after TKA, and assess changes in the range of motion (ROM) of the subtalar joint, foot posture, and ankle laxity.

Purpose of the study. We describe a new technique of talar dome osteotomy in the treatment of fixed equinovalgus deformity of the foot in patients with Fibular Hemimelia and successfully applied it in two patients. Background. Fibular Hemimelia is a congenital absence or hypoplasia of fibula with associated fixed equinovalgus deformity of the foot. Treatment for this deformity ranges from corrective osteotomy of the tibia, calcaneum to Syme's amputation. Methods. The procedure of talar dome osteotomy is best applied to children before they start to walk. Through a Cincinnati approach, fibular anlage was excised and a talar dome osteotomy performed in the axial plane to correct the valgus deformity of the ankle. Additional procedures if required include corrective osteotomy of the distal tibia to correct remaining foot deformity after the initial correction, and tendo achillis lengthening. The corrected position is then maintained with a K-wire inserted through the calcaneum, osteotamised talus up into the distal tibia. K-wire was removed at 6 weeks and foot position thereafter maintained in an AFO orthrosis with the foot slightly inverted for next 2 years. Two patients diagnosed with fibular hemimelia (Coventry and Johnson type II) underwent correction of their fixed equino-valgus deformity with the above mentioned technique at the ages of 6 and 10 months respectively. AFO orthosis was used for two years and at 5 years of follow-up the deformity has remained corrected in both the ankles. Both these patients are due to undergo limb-lengthening procedures

The August 2012 Trauma Roundup. 360. looks at: pelvic fractures, thromboembolism and the Japanese; venous thromboembolism risk after pelvic and acetabular fractures; the displaced clavicular fracture; whether to use a nail or plate for the displaced fracture of the distal tibia; the dangers of snowboarding; how to predict the outcome of lower leg blast injuries; compressive external fixation for the displaced patellar fracture; broken hips in Morocco; and spinal trauma in mainland China

Introduction. Circumferential periosteal release is a rarely reported procedure for paediatric limb lengthening. The technique involves circumferential excision of a strip of periosteum from the metaphysis of the distal femur, tibia and fibula. This study aims to determine the mid to long-term effectiveness of this technique. Materials and Methods. A retrospective case series was performed of all patients undergoing circumferential periosteal release of the distal femur and/or tibia between 2006 and 2017. Data collected included demographics, surgical indication, post-operative limb-lengths and complications. Data collection was stopped if a further procedure was performed that may affect limb-length (except a further release). Leg-length discrepancies were calculated as absolute values and as percentages of the longer limb-length. Final absolute and percentage discrepancies were compared to initial discrepancies using a paired t-test. Results. Eighteen patients (11 males) were identified, who underwent 25 procedures. The mean age at first surgery was 5.83 (SD 3.49). The commonest indication was congenital limb deficiency (13 patients). In 23 procedures the periosteum was released in two limb segments (distal femur and distal tibia), whereas in two patients it was released in a single limb segment. Five patients underwent repeat periosteal release, and one patient had three periosteal releases. Mean follow-up was 63.1 months (SD 33.9). Fifteen patients had sufficient data for statistical analysis. The mean initial absolute discrepancy was 2.01cm (SD 1.13), and the mean initial percentage discrepancy was 4.09% (SD 2.76). The mean final absolute discrepancy was 1.00cm (SD 1.62), and the mean percentage final discrepancy was 1.37% (SD 2.42). The mean reduction in absolute discrepancy was 0.52 cm (95%CI −0.04–1.08; p=0.068, paired t-test), and the mean reduction in percentage discrepancy was 2.00% (95% CI 1.02–2.98, p=<0.001 paired t-test). In five patients the operated limb overgrew the shorter limb. Conclusions. Circumferential periosteal release produces a modest decrease in both absolute and percentage limb-length discrepancy, although the outcome is variable and some patients may experience overgrowth of the operated limb

Although optimal alignment is essential for improved function and implant longevity after TKA, we have less bony landmarks of tibia relative to femur. Trans-malleolar axis (TMA) is a reference line of distal tibia in the axial plane, which externally rotated relative to a ML axis of proximal tibia. We originally defined another reference axis associated with the orientation of tibial plafond, and then measured tibial torsion in the 3D-coordinate system. Three-dimensional CAD models of 20 tibiae were reconstructed based on pre-operative CT data from OA patients (16 females and 4 males, 73.8 ± 6.9 years old). TMA was a line connecting each apex of medial and lateral malleolus. The plafond axis (PLA) that we originally defined in this study was a line connecting each midpoint of medial and lateral margin of talocrural facet. In terms of interobserver correlation coefficiency and mean errors of the designated points to define those axes, TMA was found out to be 0.982, 3.14 ± 0.47 mm (medial), and 0.988, 4.88 ± 0.59 mm (lateral). Those of PLA were 0.997, 1.97 ± 0.53 mm (medial), and 0.995, 2.02 ± 0.44 mm (lateral). The tibial torsion was 16.3 ± 6.3°with reference to TMA, and 10.2 ± 8.4°to PLA. Based on these results, as for the rotational reference axis in the axial plain of distal tibia, we consider the plafond axis to be another reliable and reproducible axis, which is expected to be applicable in preoperative planning in TKA to reduce outliers of coronal alignment

Introduction. There is no published series described change in bone mineral density (BMD) after ankle replacement. We present the results of a prospective study examining the effect of total ankle replacement (TAR) upon local bone mineral density (BMD). Aim. To design a method and assess the effect of TAR loading on local ankle bones, by analysing the BMD of different area around ankle before and after Mobility TAR. Methods. 23 patients undergoing Mobility ankle arthroplasty for osteoarthritis had preoperative bone densitometry scans of the ankle, repeated at 1 and 2 years after surgery. BMD of 2 cm. 2. areas around ankle were measured. Pre- and postoperative data were compared. Results: Mean BMD within the lateral malleolus decreased significantly from 0.5g/cm. 2. to 0.42g/cm. 2. (17%, P > 0.01), at 1 & 2 years postoperatively. Mean BMD within medial malleolus decreased slightly from 0.67g/cm. 2. to 0.64 g/cm. 2. at the same period. However BMD at medial side metaphysic of tibia increased by 7%. There was little increase in BMD in tibia just proximal to implant and at talus. Discussion and Conclusion. Absence of stress shielding around distal tibia, just proximal to tibial component and talus indicates that ankle replacements implanted within the accepted limits for implant alignment, load distal tibia and talus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in lateral malleolus. Increase BMD at tibial metaphysis, proximal to medial malleolus indicates an increase in mechanical stress which may explain occasional postoperative stress fracture of medial malleolus or medial side ankle pain

Introduction. The goal of arthrodesis around the ankle or of triple (hind foot) arthrodesis is a painless, plantigrade, and stable foot. Stress fracture is a differential diagnosis for pain following an ankle/subtalar arthrodesis. Management of stress fractures following sound ankle/subtalar fusion is extremely difficult as the entire movement tends to occur at the fracture site, hence hampering healing. Methods and materials. 33 patients underwent ankle/subtalar arthrodesis at our institute from 2000-2008. The average age of the patients was 69 years and the male: female ratio was 2:1. The minimum follow-up was for one year. Although there were some variations in technique, all the arthrodesis were performed by removal of articular cartilage, bone grafting of any defects and rigid internal fixation. Results. 2/33 patients developed a stress fracture of the distal tibia following successful ankle/subtalar fusion. An angle of ankle/subtalar fusion showed an average of 0 degrees +/− 3 degrees in the sagital plane, except for the two cases that developed the stress fracture. The angles in these cases were 13 and 11 degrees. The stress fractures occurred proximal to the level of the previous arthrodesis internal fixation devices (arthrodesis nail/cancellous screws). Intramedullary and extramedullary devices were utilised to obtain union across the stress fracture sites, without success. Discussion. Equinus of more than 10 degrees following ankle/subtalar arthrodesis is a high risk factor for developing a stress fracture of the distal tibia following ankle/subtalar arthrodesis. Stress fracture following successful ankle/subtalar arthrodesis causes severe morbidity. They are extremely difficult to treat, hence are best avoided if possible

Aims

To systematically review the predominant complication rates and changes to patient-reported outcome measures (PROMs) following osteochondral allograft (OCA) transplantation for shoulder instability.

Aims

The aim of this study was to describe the incidence of refractures among children, following fractures of all long bones, and to identify when the risk of refracture decreases.

Aims

We performed a systematic literature review to define features of patients, treatment, and biological behaviour of multicentric giant cell tumour (GCT) of bone.

Aims. The aim of this study was to report the outcome following primary fixation or a staged protocol for type C fractures of the tibial plafond. Patients and Methods. We studied all patients who sustained a complex intra-articular fracture (AO type C) of the distal tibia over an 11-year period. The primary short-term outcome was infection. The primary long-term outcome was the Foot and Ankle Outcome Score (FAOS). Results. There were 102 type C pilon fractures in 99 patients, whose mean age was 42 years (16 to 86) and 77 were male. Primary open reduction internal fixation (ORIF) was performed in 73 patients (71.6%), whilst 20 (19.6%) underwent primary external fixation with delayed ORIF. There were 18 wound infections (17.6%). A total of nine (8.8%) were deep and nine were superficial. Infection was associated with comorbidities (p = 0.008), open fractures (p = 0.008) and primary external fixation with delayed ORIF (p = 0.023). At a mean of six years (0.3 to 13; n = 53) after the injury, the mean FAOS was 76.2 (0 to 100) and 72% of patients were satisfied. Conclusion. This is currently the largest series reporting the outcome following fixation of complex AO type C tibial pilon fractures. Despite the severity of these injuries, we have demonstrated that a satisfactory outcome can be achieved in the appropriate patients using primary ORIF. Cite this article: Bone Joint J 2016;98-B:1106–11

We report a variant of tibial hemimelia in a six-year-old boy that did not comply with recognised classification systems. The femur and knee were normal, but the fibula was displaced proximally and there was severe diastasis of the proximal and distal tibiofibular joints to the extent that a grossly deformed foot articulated with the fibula and there was separate soft-tissue cover for the distal tibia and fibula. Although it would have been preferable to create a one-bone leg, amputate the foot and use the fibula as the stump for a below-knee prosthesis, local circumstances resulted in the choice of a disarticulation through the knee. This was undertaken without complications, and six months post-operatively the child was walking comfortably with a prosthesis

Trochlear dysplasia is a specific morphotype of the knee, characterized by but not limited to a specific anatomy of the trochlea. The notch, posterior femur and tibial plateau also seem to be involved. In our study we conducted a semi-automated landmark-based 3D analysis on the distal femur, tibial plateau and patella. The knee morphology of a study population (n=20), diagnosed with trochlear dysplasia and a history of recurrent patellar dislocation was compared to a gender- and age-matched control group (n=20). The arthro-CT scan-based 3D-models were isotropically scaled and landmark-based reference planes were created for quantification of the morphometry. Statistical analysis was performed to detect shape differences between the femur, tibia and patella as individual bone models (Mann-Whitney U test) and to detect differences in size agreement between femur and tibia (Pearson's correlation test). The size of the femur did not differ significantly between the two groups, but the maximum size difference (scaling factor) over all cases was 35%. Significant differences were observed in the trochlear dysplasia (TD) versus control group for all conventional parameters. Morphometrical measurements showed also significant differences in the three directions (anteroposterior (AP), mediolateral (ML), proximodistal (PD)) for the distal femur, tibia and patella. Correlation tests between the width of the distal femur and the tibial plateau revealed that TD knees show less agreement between femur and tibia than the control knees; this was observed for the overall width (TD: r=0.172; p=0.494 - control group: r=0.636; p=0.003) and the medial compartment (TD: r=0.164; p=0.516 - control group: r=0.679; p=0.001), but not for the lateral compartment (TD: r=0.512; p=0.029 - control: r=0.683; p=0.001). In both groups the intercondylar eminence width was strongly correlated with the notch width (TD: r=0.791; p=0.001 - control: r=0.643; p=0.002). The morphology of the trochleodysplastic knee differs significantly from the normal knee by means of an increased ratio of AP/ML width for both femur and tibia, a smaller femoral notch and a lack of correspondence in mediolateral width between the femur and tibia. More specifically, the medial femoral condyle shows no correlation with the medial tibial plateau

We undertook a prospective study to analyse the outcome of 48 malunited pronation-external rotation fractures of the ankle in 48 patients (25 females and 23 males) with a mean age of 45 years (21 to 69), treated by realignment osteotomies. The interval between the injury and reconstruction was a mean of 20.2 months (3 to 98). . In all patients, valgus malalignment of the distal tibia and malunion of the fibula were corrected. In some patients, additional osteotomies were performed. Patients were reviewed regularly, and the mean follow-up was 7.1 years (2 to 15). . Good or excellent results were obtained in 42 patients (87.5%) with the benefit being maintained over time. Congruent ankles without a tilted talus (Takakura stage 0 and 1) were obtained in all but five cases. One patient required total ankle replacement

Introduction. Our unit has extensive experience with the use of Ilizarov circular frames for acute fracture and nonunion surgery. We have observed and analysed fracture healing patterns which question the role of relative stability in fracture healing and we offer limb mechanical axis restoration as a more important determinant. Aim. To assess for the presence of external callus, when only relative stability has been achieved but with anatomical restoration of the mechanical axis (ARMA). Methods. We retrospectively reviewed diametaphyseal proximal and distal tibial fractures treated with Ilizarov frame fixation in our unit between 2009 and 2017. We also reviewed cases where the Ilizarov frame technique had been used for complex femoral and humeral non-unions. Radiographs in 4 views were reviewed to assess bone healing, the presence of external callus and correction of lower limb mechanical axis. Results. 45 tibial plateau fractures, 42 distal tibial fractures and 20 humeral and 3 femoral non-unions were reviewed. Where ARMA was achieved, bone healing was observed to occur without external callus. ARMA proved more challenging in the distal tibia and where ARMA was not achieved external callus was visible during fracture healing. Conclusion. ARMA bone healing is reliable and occurs without formation of external callus, despite relative stability. This would suggest that external callus is produced not in response to just the magnitude of strain but also the direction of strain. Restoration of the mechanical axis is an important step in achieving union and needs to be considered when fixing fractures or treating non-unions

Aim. This study describes the histologic changes seen with a gentamicin-eluting synthetic bone graft substitute (BGS)(1) in managing bone defects after resection of chronic osteomyelitis (cOM). Method. 154 patients with mean follow-up of 21.8 months (12–56) underwent treatment of cOM with an antibiotic-loaded BGS for defect filling. Nine patients had subsequent surgery, not related to infection recurrence, allowing biopsy of the implanted material. These biopsies were harvested between 19 days and two years after implantation, allowing a description of the material's remodelling over time. Samples were fixed in formalin and stained with haematoxylin-eosin. Immunohistochemistry, using an indirect immunoperoxidase technique, identified the osteocyte markers Dentine Matrix Protein-1 (DMP-1) and Podoplanin, the macrophage/osteoclast marker CD68, and the macrophage marker CD14. Results. The material was actively remodelled and was osteoconductive. There was evidence of osteoblast recruitment, leading to osteoid and intramembranous formation of woven and lamellar bone on the material's surface, seen most prominently in areas of well-vascularised fibrous tissue. Osteocytes in woven bone expressed the markers DMP-1 and Podoplanin. No cartilage or endochondral ossification was seen. There was a prominent (CD14+/ CD68+) macrophage response to the BSG and macrophages within reparative cellular and collagenous fibrous tissue. In biopsies taken between 4 and 5 months, there were bone trabeculae containing BGS of mainly woven but partly lamellar type. Giant cells on the surface of newly formed mineralised osteoid and woven bone expressed an osteoclast phenotype (CD68+/CD14-). In later biopsies (up to 2 years), larger bone trabeculae were seen more frequently within well-vascularised reparative fibrous tissue. The BGS was replaced with predominantly lamellar bone. One biopsy was taken from an extraosseous leak of BGS into the soft tissues, behind the distal tibia. The histology showed a heavy macrophage infiltrate, but notably no evidence of osteoid or bone formation in the material or surrounding soft tissues. Conclusion. There was clear evidence that this BGS is osteoconductive with first osteoid then woven and lamellar bone being formed. DMP-1 and podoplanin-expressing osteocytes present in woven and lamellar bone demonstrate osteoclastic bone remodelling. Increased lamellar bone was noted in later samples and bone formation was most prominent in well-vascularised areas. There was on-going remodelling of the material beyond one year. The BGS did not ossify in soft tissue. The hydroxyapatite scaffold in this material is probably responsible for its high osteoconductivity and potential to be transformed into bone