Background: Injuries to ankle joint consist 12% of visits to emergency departments. In spite of the common occurrence of ankle sprain, syndesmosis injuries are rare, but very debilitating and frequently misdiagnosed. Methods: Among 100 patients with ankle sprain we evaluated the incidence of syndesmosis sprain by MRI of the ankle. Adults who had acute ankle sprain with no fracture and examined on the same day that injury had took place were being included in the survey. Results: Out of 100 patients with ankle injury, four had syndesmosis sprain. Three patients had partial tear of syndesmotic complex and one had complete tear. All injuries occurred in sports except one which had happened in an accident, and two of the patients were athletes. Anterior inferior tibiofibular ligament was the most common ruptured ligament. Conclusions: We reported a four-percent incidence of this injury. Our high rate of this injury emphasized on the fact that all suspicious cases should go under more accurate investigation not to miss this diagnosis

The unresolved ankle sprain is one of the most common referrals to a specialist orthopaedic foot & ankle surgeon. These injuries occur in sports people as well as workers, and frequently cause prolonged sporting inactivity or time off work. The unresolved ankle sprain can be defined as that injury which does not resolve with appropriate conservative treatment within six weeks. The pathology causing an ankle sprain to be unresolved can involve soft tissue or bony structures. Thorough clinical and radiological assessment is necessary to secure the diagnosis, institute effective surgical treatment and counsel the patient accurately with regards to prognosis for the injury. This paper discusses the differential diagnosis & surgery in order to resolve prolonged disability after the common ankle sprain

Purpose: The aim of this paper is to present a new surgical method for the reconstruction of the recurrent sprain of the ankle. Material – Methods: From 1980 until 1997, 17 patients 3 females and 14 males, average age 25.53 (19 – 44) underwent surgery suffering recurrent sprain of the ankle. In 11 patients the right ankle was involved and in 6 patients the left ankle. The cause of the injury was: athletic activities in 9 cases, weekend activities in 7 cases and daily activities in 1 case. The patients were suffering from ankle instability 4–15 years prior the operation. All the patients underwent reconstructive surgery of the anterolateral elements (capsule and ligaments) according to senior author’s method. This included shortening of the anterolateral elements, capsule and ligaments, overlaping the anterolateral part over the anterolateral one in such a way, that the anterior drawer and varus tests were negative with the patient under anaesthesia. Results: The follow up is 2–12 years. A patient underwent for a second time surgery, because of a new injury. In 2 patients early signs of ankle osteoarthritis. In the rest of them, restoration of the function of the ankle joint was excellent, obtaining full activities 3 months postperatively. Conclusion: This surgical method for the reconstruction of the recurrent sprain of the ankle is considered satisfactory and when indicated allows young patients and athletes to participate in a rather short period of time, in their previous level of activities

Purpose: Pain occasionally develops in the posterior tibial tendon after chronic sprains, whose pathology is not known yet. We inserted an endoscope (tendoscope) into the tendon sheath of the tibialis posterior and treated based on the observation of its pathology. Subjects and methods: Subjects were patients who had complained pain in the posterior tibial tendon after ankle sprain. The interval from the injury to the tendo-scope ranged from one month to one year and 8 months with an average of 9 months. There were 18 patients (11males, 7females). The age ranged from 18 to 33 years with an average of 24 years. For initial treatment, cast fixation, and orthoses were employed in 10 patients. Other 8 patients were left with bandage alone. For these patients, a 2.4mm-diameter endoscope was inserted into the tendon sheath. Results: Synovia proliferation was found in all the cases, and vicula in the tendon sheath disappeared. Synovia proliferation was found in all patients and erosion of the tendon was observed in 8 patients. In other 3 patients, injured sliding floor of the posterior tibial tendon was found. For treatment, synovectomy and smoothing of the sliding floor were performed. All the patients had improvement of pain and returned to sports with the former level. Discussion: It has been known that, in some cases, pain emerges in the posterior tibial tendon after ankle sprain. Its pathology has remained unknown. It is suggested that injuries in the tendon sheath of the tibialis posterior, sliding floor of the tendon, and deltoid ligament associated with the sprain may have caused inflammations, which has developed synovia proliferation. It is thought posterior tibial tendon is often injured after ankle sprain

1. Partial diastasis of the tibio-fibular syndesmosis is believed to be common, but it is often overlooked as a cause of recurrent sprains of the ankle. 2. The treatment of recurrent sprains of the ankle by stabilising the inferior tibio-fibular joint with a lag screw is described. The method has been used in seventy-five patients aged between sixteen and sixty-five years. The longest follow-up has been six years

This study assessed the effect of litigation on the long-term outcome and recovery of ankle inversion injuries. 167 patients from an accident and emergency database were contacted by telephone. Thirty participants were litigating and these candidates were randomly matched with 30 non-litigating patients with respect to mechanism of injury. Each group had 27 patients with ankle sprains because of falls/trips and 3 after road traffic accidents. Radiographs when available of each participant were examined and the degree of soft tissue swelling over the lateral malleolus was assessed. 76.6% of litigants reported incomplete recovery compared to 26.7% of non-litigants. The median period of sleep disturbance, swelling, limping and non-weight-bearing was 1.5 days, 2.0 weeks, 2.0 weeks and 1.0 weeks for the non-litigants. This compares to 3.5 days, 10.0 weeks, 8.0 weeks and 8.0 weeks for the litigants using the same variables (p< 0.0001 in all cases). Where ankle radiographs had been taken swelling was equal in each group (9.0mm over lateral malleolus (30% of litigants incorrectly suggested an ankle x-ray had been taken, when it had not)). The majority of litigants (65%) thought that physiotherapy would not be beneficial in rehabilitating their ankle (35% non-litigants). It appears that litigation has a negative effect on the outcome and recovery of ankle sprains

Sprain of the pisiform triquetral joint is a definite clinical entity. It presents as a "tenosynovitis" of the flexor carpi ulnaris muscle from which it can be distinguished by the tests described. The disability in most cases is such that operation is justifiable. Fusion of the pisiform-triquetral joint is preferred to excision of the pisiform because it restores stability to the wrist with the least disturbance to related structures

Purpose of the study: High-energy varus or valgus ankle trauma causes severe injury to the capsule and ligaments. We describe a presentation associating massive tears of the lateral/medial collateral ligaments with a transversal wound of the corresponding malleolus. This wound results from excessive tension on the skin cause by the major varus/valgus. We have defined this injury as an open and severe ankle sprain (OSAS). Material and method: This was a retrospective analysis. We search the databases of three participating centres using the corresponding diagnostic and therapeutic codes from January 2005 to January 2009. The identified files were screened to select patients with OSAS. Results: There were 11 cases of OSAS. Eight involved the lateral side of the ankle and three the medial side. Mean age was 41 years (range 21–45). All patients were victims of a high-energy trauma (five motorcycle accidents) and four patients had fallen from a high point. Associated injuries were tendon section (n=3), section of the deep fibular nerve (n=2), and section of the anterior tibial artery (n=1). Pneumarthrosis was the only visible anomaly on the plain x-rays of seven ankles. Diagnosis was confirmed preoperatively in all cases clinically with varus-valgus stress manoeuvres. Conclusion: OSAS is a rare misleading injury. Confusion with a common wound is possible. The risk is to miss acute instability and thus its treatment. The diagnosis should be proposed for all transversal wounds without contusion over the malleolus with normal x-rays

Purpose of the study: Appropriate management of chronic sprains of the scapholunate joint remains a subject of debate. Different surgical techniques have been proposed, from partial arthrodesis of the carpus to ligamentoplasty. We opted for scaphocapitatum arthrodesis. The purpose of this report was to assess clinical and radiological outcome. Material and methods: From 1997 to 2001, 13 arthrodeses (13 patients) were performed for this indication. The procedure involved two screws (n=11), one screw and stapling (n=1), and stapling alone (n=1). A free autologous graft was used in all cases. Mean patient age was 40 years (12 males and one female). These patients were victims of sports accidents (n=8) or occupational accidents (n=5). Mean follow-up was 26 months (range 24–31 months). Variables noted were joint mobility, pain, grasp force and pinch force. Wrist x-rays were used to measure the height of the carpus and the radio-lunate angle. Results: A 31% loss in the radial inclination was noted as as a 14.5% loss in the ulnar inclination. Dorsal flexion of the wrist declined from 60° to 48°, palmar flexion from 47° to 28°. Stiffness mainly involved the radial inclination and palmar flexion. Grasp and Pinch forces improved (125° on average). All patients excep one presented residual pain. Six patients complained of pain only for efforts and six presented invalidating pain. Only seven patients were able to resume their occupational activity. There were three cases of nonunion which required revision to achieve final bone healing (poor outcome). Carpal height improved (0.47±0.54). The mean radiolunate angle at last follow-up was 11°. DISI persisted in only one wrist. Discussion: This technique reduced wrist mobility. For all patients, the dorsal approach to the wrist produced inevitable stiffness. Radial inclination declines due to the intracarpal fusion. This arthrodesis enabled restitution of the carpal height and partially corrected for the DISI. This operation did not provide pain relief but did not alter the carpal x-ray. We raise the question of the pertinence of associating this type of arthrodesis with total denervation of the wrist

Injury to the perforating branch of the peroneal artery has not been reported previously as a cause of acute compartment syndrome following soft-tissue injury to the ankle. We describe the case of a 23-year-old male who sustained such an injury resulting in an acute compartment syndrome. In a review of the literature, we could find only five previous cases, all of which gave rise to a false aneurysm which was detected after the acute event.

A consecutive series of 100 cases of wrist injury, other than those referred with a radial fracture, have been reviewed to determine the incidence of acute scapholunate instability; a "clenched fist" radiograph was used in addition to the routine scaphoid views. Of 19 patients with an increase in the scapholunate gap, five were eventually considered to have significant scapholunate instability, two in association with Colles' fractures. Injuries producing significant ligamentous damage and carpal instability may be as common as scaphoid fractures. They require special consideration in diagnosis and management.

Aims. The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates. Methods. PubMed (National Library of Medicine) and Scopus (Elsevier) databases were searched. Articles were eligible for inclusion if they reported incidence rate (or count with population at risk), contained data on adult population, and were written in English language. The number of cases and population at risk were collected, and the pooled incidence rates (per 100,000 person-years) with 95% confidence intervals (CIs) were calculated by using either a fixed or random effects model. Results. The screening of titles yielded 206 articles eligible for inclusion in the study. Of these, 173 (84%) articles provided sufficient information to be included in the pooled incidence rates. Incidences of fractures were investigated in 154 studies, and the most common fractures in the whole adult population based on the pooled incidence rates were distal radius fractures (212.0, 95% CI 178.1 to 252.4 per 100,000 person-years), finger fractures (117.1, 95% CI 105.3 to 130.2 per 100,000 person-years), and hip fractures (112.9, 95% CI 82.2 to 154.9 per 100,000 person-years). The most common sprains and dislocations were ankle sprains (429.4, 95% CI 243.0 to 759.0 per 100,000 person-years) and first-time patellar dislocations (32.8, 95% CI 21.6 to 49.7 per 100,000 person-years). The most common injuries were anterior cruciate ligament (17.5, 95% CI 6.0 to 50.2 per 100,000 person-years) and Achilles (13.7, 95% CI 9.6 to 19.5 per 100,000 person-years) ruptures. Conclusion. The presented pooled incidence estimates serve as important references in assessing the global economic and social burden of musculoskeletal injuries. Cite this article: Bone Joint Res 2022;11(11):814–825

The August 2023 Wrist & Hand Roundup360 looks at: Complications and patient-reported outcomes after trapeziectomy with a Weilby sling: a cohort study; Swelling, stiffness, and dysfunction following proximal interphalangeal joint sprains; Utility of preoperative MRI for assessing proximal fragment vascularity in scaphoid nonunion; Complications and outcomes of operative treatment for acute perilunate injuries: a systematic review; The position of the median nerve in relation to the palmaris longus tendon at the wrist: a study of 784 MR images; Basal fractures of the ulnar styloid? A randomized controlled trial; Proximal row carpectomy versus four-corner arthrodesis in SLAC and SNAC wrist; Managing cold intolerance after hand injury: a systematic review

There is a disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. Anterior cruciate ligament ruptures are between two and eight times more common than in males, and females also have a higher incidence of ankle sprains, patellofemoral pain, and bone stress injuries. The sequelae of such injuries can be devastating to an athlete, resulting in time out of sport, surgery, and the early onset of osteoarthritis. It is important to identify the causes of this disparity and introduce prevention programmes to reduce the incidence of these injuries. A natural difference reflects the effect of reproductive hormones in females, which have receptors in certain musculoskeletal tissues. Relaxin increases ligamentous laxity. Oestrogen decreases the synthesis of collagen and progesterone does the opposite. Insufficient diet and intensive training can lead to menstrual irregularities, which are common in female athletes and result in injury, whereas oral contraception may have a protective effect against certain injuries. It is important for coaches, physiotherapists, nutritionists, doctors, and athletes to be aware of these issues and to implement preventive measures. This annotation explores the relationship between the menstrual cycle and orthopaedic sports injuries in pre-menopausal females, and proposes recommendations to mitigate the risk of sustaining these injuries. Cite this article: Bone Joint J 2023;105-B(7):723–728

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

Ligament integrity is directly associated with ankle stability. Nearly 40% of ankle sprains result in chronic ankle instability, affecting biomechanics and potentially causing osteoarthritis. Ligament replacement could restore stability and avoid this degenerative pathway, but a greater understanding of ankle ligament behaviour is required. Additionally, autograft or allograft use is limited by donor-site morbidity and inflammatory responses respectively. Decellularised porcine grafts could address this, by removing cellular material to prevent acute immune responses, while preserving mechanical properties. This project will characterise commonly injured ankle ligaments and damage mechanisms, identify ligament reconstruction requirements, and investigate the potential of decellularised porcine grafts as a replacement material. Several porcine tendons were evaluated to identify suitable candidates for decellularisation. The viscoelastic properties of native tissues were assessed using dynamic mechanical analysis (DMA), followed by ramp to ‘sub-rupture’ at 1% strain/s, and further DMA. Multiple samples (n=5) were taken along the graft to assess variation along the tendon. When identifying suitable porcine tendons, a lack of literature on human ankle ligaments was identified. Inconsistencies in measurement methods and properties reported makes comparison between studies difficult. Preliminary testing on porcine tendons suggested there is little variation in viscoelastic properties along the length of tendon. Testing also suggested strain rates of 1%/s sub-rupture was not large enough to affect viscoelastic properties (no changes in storage or loss moduli or tanẟ). Further testing is underway to improve upon low initial sample numbers and confirm these results, with varying strain rates to identify suitable sub-rupture sprain conditions. This work highlights need for new data on human ankle ligaments to address knowledge gaps and identify suitable replacement materials. Future work will generate this data and decellularise porcine tendons of similar dimensions. Collagen damage will be investigated using histology and lightsheet microscopy, and viscoelastic changes through DMA

Acute lateral ankle sprain accounts for 85% of sprains. The lateral sprain is associated with other ligament injuries e.g. medial and syndesmosis sprain. Long-term, approximately 20% of acute lateral sprains develop into chronic lateral ankle instability (CLAI) which includes persistent pain, and recurring ankle sprains. This study evaluated the grade of an ankle ligament injury by ultrasonography (US) and compared the findings to the outcome of patient-reported questionnaires. 48 subjects (18–40 years) diagnosed with an ankle sprain attended a clinical and US examination of ankle ligaments within two weeks after the sprain. Evaluation was done by US of acute lateral ligament injuries (ATFL, CFL), syndesmosis injury (AiTFL), and medial injury (dPT, TCt) only in participants with the positive clinical signs of medial injury. Participants were then mailed a questionnaire (PROMQ) every third month for a year. 29 women and 19 men participated with a mean age at 26.50 years. One-year follow-ups need to be analyzed further for final results. Temporary results include data based on the initial 26 patients: Two clinical signs statistically correlated. Multiple logistic regression analysis confirmed the results. Positive palpated tenderness AiTFL predicted with partial ruptured ATFL and reported pain during active plantar flexion of ankle predicted with normal CFL confirmed by the US. Patients with partial rupture of ATFL presented with tenderness at AiTFL point. Patients presenting with intact CFL reported pain during active plantar flexion. Compared to the US findings, the overall examinations were inconclusive in predicting ATFL, CFL, AiTFL, and medial ligament injuries

Ankle sprains are common athletic injuries, with a peak lifetime incidence between the ages of 15 and 19 years, especially in young males. However, an unclear history, an imprecise physical exam, and unhelpful radiographies lead to frequent misdiagnosis of paediatric ankle traumas, and subsequently, inappropriate treatment. Improper management may lead to residual pain, instability, slower return to physical activity, and long-term degenerative changes. The purpose of this study was to evaluate the initial management and treatment of acute paediatric ankle sprains at our center, a tertiary care paediatric hospital. Our hypothesis was that the initial diagnosis is often incorrect, and treatment varies considerably amongst orthopaedic surgeons. We conducted a retrospective study of all cases of ankle sprains and Salter-Harris one (SH1) fractures referred to our orthopaedic surgery service between May and August 2014. Exclusion criteria included ankle fractures other than SH1 types, and cases where treatment was initially undertaken elsewhere before referral to our service. Patients were evaluated on a clinical and radiographic basis. Primary outcome was the difference between initial and final diagnosis. Secondary outcome was variation in immobilisation duration for each diagnosis. The main variables we considered were age, sex, mechanism of trauma, referral delay, patient symptoms, physical exam findings, radiographic findings, type and duration of immobilisation, prescription of any medication, and referral to physical therapy. A total of 3047 patients were reviewed and 31 cases matched our inclusion criteria, comprised of 17 girls and 14 boys, with a mean age of 10.4 years. Patients were seen at a mean of 10.3 days after injury. Initial diagnosis was SH1 fracture in 20 cases, acute ankle sprain in 8 cases, and uncertain in 3 cases. Final diagnosis was SH1 fracture in 11 cases, acute ankle sprain in 13 cases, uncertain in 5 cases, and other in 3 cases. During follow up, 48.5% of cases saw a change in diagnosis. Forty five percent (9/20) of cases initially diagnosed as SH1 fractures proved to be incorrect, with 55.5% (5/9) of these being ultimately diagnosed as acute ankle sprains. Amongst cases initially diagnosed as acute ankle sprains, 37.5% (3/8) received a different final diagnosis. Duration of immobilisation was significantly different between acute ankle sprain and SH1 fracture groups, with an average of 17.3 days and 26.1 days, respectively. Physical therapy was prescribed to 33.3% of acute ankle sprains and 9.1% of SH1 fractures. Initial distinction between acute ankle sprains and SH1 fractures can be difficult in paediatric ankle trauma. Case management and specific treatments vary considerably, as there is neither an evaluation algorithm nor consensus on treatment of these paediatric pathologies. This study reinforces the need to develop a systematic diagnostic and treatment protocol for paediatric ankle sprains

Ankle sprains are common injuries. Most of them involve the lateral ligament complex. 20–40%% of these injuries will go onto develop symptomatic chronic lateral instability (CLI) and require surgical intervention. The gold standard surgical treatment remains the Brostom-Gould. There are however certain scenarios where this may be unsuitable, such as in hyperlaxity, poor native tissue or revision surgeries. In these situations, a reconstruction with some form of augmentation or grafting is necessary. The anterior half of peroneus longus (AHPL) has gained in popularity as an autograft due to its favourable tendon properties, ease of harvesting, and low reported morbidity. This technique has been adopted by the senior author in these situations. Our primary aim was to assess patient reported outcomes and satisfaction following this surgery. Our secondary objectives were to assess return to sports, donor site morbidity and to report any surgical complications. We performed a retrospective single surgeon study on all patients who underwent CLI reconstruction using the anterior half of peroneus longus between 2014 and 2021. Data was collected prospectively. The Karlsson foot and ankle scoring chart as well as a simple satisfaction table were used to assess outcomes. Minimum follow up was 1 year. 44 patients met the inclusion criteria. 23 women, 21 men. The average age was 37.0 (+−13.5). 24 were very satisfied with the surgery, 10 were satisfied, 6 were fair and 4 were dissatisfied. The average Karlsson score improved from 65/90 (34–77) to 85/90 (range 45–90). The average return to sport was 5 months. There was 1 non-surgical complication recorded. There was no repeat surgery for a complication, or recurrent instability and no donor-site morbidity was reported. The results of our study demonstrates that the CLIR using AHPL is a reliable, predictable and safe

The October 2012 Wrist & Hand Roundup. 360. looks at: osteoarticular flaps to the PIPJ; prognosis after wrist arthroscopy; adipofascial flaps and post-traumatic adhesions; the torn TFCC alone; ulna-shortening osteotomy for ulnar impaction syndrome; Dupuytren’s disease; when a wrist sprain is not a sprain; and shrinking the torn intercarpal ligament

Introduction. Early clinical examination combined with MRI following a high ankle sprain allows accurate diagnosis of syndesmosis instability. However, patients often present late, and for chronic injuries clinical assessment is less reliable. Furthermore, in many centres MRI may be not be readily available. The aims of the current study were to define MRI characteristics associated with syndesmosis instability, and to determine whether MRI patterns differed according to time from injury. Methods. Retrospectively, patients with an unstable ligamentous syndesmosis injury requiring fixation were identified from the logbooks of two fellowship trained foot and ankle surgeons over a five-year period. After exclusion criteria (fibula fracture or absence of an MRI report by a consultant radiologist), 164 patients (mean age 30.7) were available. Associations between MRI characteristics and time to MRI were examined using Pearson's chi-square tests or Fisher's exact tests (significance set at p< 0.05). Results. Overall, 100% of scans detected a syndesmosis injury if performed acutely (within 6 weeks of injury), falling to 83% if performed after 12 weeks (p=0.001). In the acute group, 93.5% of patients had evidence of at least one of either PITFL injury (78.7%), posterior malleolus bone oedema (60.2%), or a posterior malleolus fracture (15.7%). In 20% of patients with a posterior malleolus bone bruise or fracture, the PITFL was reported as normal. The incidence of posterior malleolus bone bruising and fracture did not significantly differ according to time. Conclusion. For unstable ligamentous syndesmosis injuries, MRI becomes less sensitive over time. Importantly, posterior malleolus bone oedema or fracture may be the only evidence of a posterior injury. Failure to recognise instability may lead to inappropriate management of the patient, long term pain and arthritis. We therefore advocate early MRI as it becomes more difficult to ‘grade’ the injury if delayed

Vacuum orthoses are being applied in the care of patients with foot and lower leg conditions, as ankle fractures or sprains. The lower leg is protected and immobilized, which increases mobility. Due to the design, the orthoses lead to a difference in leg length, i.e. the side with the orthosis becomes longer, which changes the gait kinematics. To prevent or mitigate the unfavourable effects of altered gait kinematics, leg length-evening devices (shoe lifts) are offered that are worn under the shoe on the healthy side. Our aim was to evaluate the effect of such a device on the normality of gait kinematics. Gait analysis was conducted with 63 adult, healthy volunteers having signed an informed consent form that were asked to walk on a treadmill at a speed of 4.5km/h in three different conditions:. barefoot - as reference for establishing the normality score baseline. with a vacuum orthosis (VACOPed, OPED GmbH, Germany) and a sport shoe. with a vacuum orthosis and a shoe lift (EVENup, OPED GmbH, Germany). Data was sampled using the gait analysis system MCU 200 (LaiTronic GmbH, Austria). The positions of the joint markers were exported from the software and evaluated for the joint angles during the gait cycle using custom software (implemented in DIAdem 2017, National Instruments). A normality score using a modification of the Gait Profile Score (GPS) was calculated in every 1%-interval of the gait cycle and evaluated with a Wilcoxon signed rank test. The GPS value was reduced by 0.33° (0.66°) (median and IQR) while wearing the shoe lift. The effect was statistically significant, and very large (W = 1535.00, p < .001; r (rank biserial) = 0.52, 95% CI [0.29, 0.70]). The significant reduction of the GPS value indicates a more normal gait kinematics while using the leg length-evening device on the contralateral shoe. This rather simple and inexpensive device thus might improve patient comfort and balance while using the vacuum orthoses

High ankle sprains (HAS) cause subtle lesions in the syndesmotic ligaments of the distal tibiofibular joint (DTFJ). Current intrinsic anatomical parameters of the DTFJ are determined based on 2D imaging and uncertainty remains whether they differ in a HAS patients. The aim of this study is therefore two-fold: radiographic parameters will be determined in 3D and compared in a healthy vs sprained group. Ten patients with a mean age of 42,56 (SD = 15,38) that sustained a HAS and twenty-five control subjects with a mean age of 47,44 (SD = 6,55) were retrospectively included. The slices obtained from CT analysis were segmented to have a 3D reconstruction. The following DTFJ anatomical parameters were computed using CAD software: incisura width, incisura depth, incisura length, incisura angle, and incisura-tibia ratio. The mean incisura depth in the sprained group was 3,93mm (SD = 0,80) compared to 4,76 mm (SD = 1,09) in the control group, which showed a significant difference (P < 0.05). The mean incisura length in the group of patients with HAS was 30,81 mm (SD = 3,17) compared to 36,10mm (SD = 5,27) in the control group which showed a significant difference (P < 0.05). The other DTFJ anatomical parameters showed no significant difference. This study shows a significant difference in both incisura depth and incisura length between HAS patients and control subjects. These parameters could be used to identify potential anatomical intrinsic risk factors in sustaining a HAS

Whilst lateral ankle sprain is often considered a benign injury it represents between 3–5% of all A&E visits in the UK. The mechanical characteristics of ankle ligaments under sprain-like conditions are scarcely reported. The lateral collateral ankle ligaments were dissected from n=6 human cadaveric specimens to produce individual bone-ligament-bone specimens. An Instron Electropuls E10000 was used to uni-axially load the ankle ligaments in tension. The ligaments were first preconditioned between 2 N and a load value corresponding to 3.5% strain for 15 cycles and then strained to failure at a rate of 100%/s. The mean ultimate failure loads and their standard deviations for the anterior talofibular (ATFL), calcaneofibular (CFL) and posterior talofibular (PTFL) ligaments are 351.4±105.6 N, 367.8±76.1 N and 263.6±156.6 N, respectively. Whilst the standard deviation values are high they align with those previously reported for ankle ligament characterisation. The large standard deviations are partly due to the inherent variability of human cadaveric tissue but could also be due to varying previous activity levels of participants or a prior unreported ankle sprain. Although the sample size is relatively small the results were stratified to identify any potential correlations of age, BMI and weight with ultimate load. A strong Pearson correlation (r=0.919) was found between BMI and ultimate load of the CFL but a larger sample size is required to confirm a link. The ligament failure modes were observed and categorised as avulsion or intra-ligamentous failure. The ATFL avulsed from the fibula in five instances and intra-ligamentous failure occurred once. The CFL avulsed from the fibula twice and failed four times through intra-ligamentous failure. Finally, the PTFL avulsed from the fibula once, avulsed from the talus once and failed through intra-ligamentous failure in four instances. The results identify the forces required to severely sprain the lateral collateral ankle ligaments and their failure modes

Ankle sprains in the athlete are one of the most common injuries, and syndesmosis type sprains seem to becoming diagnosed at an increasing rate. There still exists a paucity of information on optimal conservative and operative management. Treatment. Because of the spectrum of injury, there is a spectrum of treatment. if there is mortise widening, operative stabilization is required. if the mortise is normal, even with external rotation stress test positive, conservative treatment has been employed. staged conservative regimen directed at reducing pain and swelling acutely, at regaining range of motion and strength subacutely, and then progressed to functional training and finally return to sport. The timeframe for these was in the range of 2 to 6 weeks without very specific progression criteria. In the athlete, pain with rotational stress, greater severity of sprain, may treat operatively to stabilize the syndesmosis and aggressive rehab with earlier return to sport. Tightrope vs screw fixation vs both. Use of arthroscopy. Chronic sprains with recalcitrant pain and functional instability usually require operative treatment. very poor evidence exists as to the timing or type of procedure. Arthroscopy is required to confirm the diagnosis, treat intraarticular problems, and provide fixation of the distal tibiofibular syndesmosis. The postoperative regimen used is generally the same as the one used when treating an acute syndesmosis disruption. Tight rope vs Screw Fixation. clinical studies tightrope fixation has been acceptable and comparable to screw fixation. laboratory studies demonstrate comparable construct stability in the laboratory/cadaveric setting. indications for tightrope fixation are becoming more clear with more experience. my indications:. syndesmotic sprains with complete or incomplete disruption. fractures with syndesmotic disruption augment with screws, leave in place following screw removal. Summary and Controversies. Syndesmotic or high ankle sprains continue to be a common injury that result in significant time lost from sport. The conclusion that can be drawn from the current evidence is that the current diagnostic process probably fails to clearly assess the severity of the injury, which reduces the likelihood of accurately predicting the time lost from sport. Syndesmosis sprains can be a significant injuries that result in an inability to play sports for significant periods of time(up to 137 days). We need to be able to identify the more severe ones earlier in order to improve their treatment, perhaps lead to operative stabilization. Tightrope fixation avoids screw removal, minimally invasive, permanent stabilization

Ankle sprains have been shown to be the most common sports related injury. Ankle sprain may be classified into low ankle sprain or high ankle sprain. Low ankle sprain is a result of lateral ligament disruption. It accounts for approximately 25% of all sports related injuries. The ankle lateral ligament complex consists of three important structures, namely the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). The ATFL is the weakest and most easily injured of these ligaments. It is often described as a thickening of the anterolateral ankle capsule. The ATFL sits in a vertical alignment when the ankle is plantarflexed and thus is the main stabiliser against an inversion stress. T he CFL is extracapsular and spans both the tibiotalar and talocalcaneal joints. The CFL is vertical when the ankle is dorsiflexed. An isolated injury to the CFL is uncommon. Early diagnosis, functional management and rehabilitation are the keys to preventing chronic ankle instability following a lateral ligament injury. Surgery does not play a major role in the management of acute ligament ruptures. Despite this up to 20% of patients will develop chronic instability and pain with activities of daily living and sport especially on uneven terrain. Anatomic reconstruction for this group of patients is associated with 90% good to excellent results. It is important that surgery is followed by functional rehabilitation. One of the aims of surgery in patients with recurrent instability is to prevent the development of ankle arthritis. It should be noted that the results of surgical reconstruction are less predictable in patients with greater than 10 year history of instability. Careful assessment of the patient with chronic instability is required to exclude other associated conditions such as cavovarus deformity or generalised ligamentous laxity as these conditions would need to be addressed in order to obtain a successful outcome. High ankle sprain is the result of injury to the syndesmotic ligaments. The distal tibiofibular joint is comprised of the tibia and fibula, which are connected by anterior inferior tibiofibular ligament, interosseous ligament and the posterior inferior tibiofibular ligament (superficial and deep components). The mechanism of injury is external rotation and hyperdorsiflexion. High index of suspicion is required as syndesmotic injuries can occur in association of low ankle sprains. The clinical tests used in diagnosing syndesmotic injuries (external rotation, squeeze, fibular translation and cotton) do not have a high predictive value. It is important to exclude a high fibular fracture. Plain radiographs are required. If the radiograph is normal then MRI scan is highly accurate in detecting the syndesmotic disruption. Functional rehabilitation is required in patients with stable injuries. Syndesmotic injuries are often associated with a prolonged recovery time. Accurate reduction and operative stabilisation is associated with the best functional outcome in patients with an unstable syndesmotic injury. Stabilisation has traditionally been with screw fixation. Suture button syndesmosis fixation is an alternative. Early short-term reviews show this alternate technique has improved patient outcomes and faster rehabilitation without the need for implant removal

Introduction: Posttraumatic osteoarthritis of the ankle joint usually occurs secondary to an intraarticular fracture of the weight bearing ankle joint. The question whether also recurrent ankle sprain and /or chronic instability alone can cause this entity, is, however, still a question to debate. The aim of this retrospective study was, therefore, to analyse the history and findings of a consecutive series of patients that were treated for post-traumatic end-stage osteoarthrosis of the ankle. Methods: The complete database (including physical exam, standard radiographs, patient questionnaire and AOFAS hindfoot score) of all patients was analysed. Results: Out of 268 patients (females, 135 patients; males, 133) 221 (82.5%) had had a fracture (Fx) and 47 (17.5%) suffered from chronic ankle instability with recurrent sprains (but did not have a fracture). The latter group could be subdivided into 29 (10.8%) patients with recurrent sprains (RS) and 10 (6.7%) patients with only a single sprain (SS). The mean (range) delay between primary trauma and surgical treatment for endstage osteoarthritis was 21.1 (1–58) months for Fx, 37.07 (1–61) months for RS and 22.5 (5–48) months for SS. Conclusion: Obviously, not only fractures, but also severe sprains and /or chronic instability play an important role as a cause of end stage osteaorthrosis of the ankle joint. The obtained results suggest that a single severe sprain (dislocation) can cause similar articular damages to an intraarticular fracture, as the time to develop osteoarthrosis does not differ. This is in contrast to the current opinion that ankle sprain, in most instances, does not result in symptomatic articular degeneration

Introduction: The factors causing chronic instability, a common sequela of ankle inversion sprains are unclear, despite wide investigation. However, few studies have examined potential factors during the injuring movement. We therefore measured the ability of dancers to control ankle movement during quiet stance and after a perturbation into inversion in a group with chronic instability (N=16) and healthy controls (N=26). Methods: Control of ankle movement was determined by the magnitude of lateral oscillation at the ankle, measured by a 3SPACE Fastrak. The oscillation was measured during single leg stance (baseline oscillation) for two foot positions, flat and demi-pointe. In both positions, the time taken to return to the baseline oscillation after an inversion perturbation (perturbation time) of 15° for the flat foot and 7.5° for the demi-pointe position was also determined. Results: The baseline oscillation was significantly smaller (P< 0.005) on the demi-pointe for the sprained group (2.5 ± 0.5 mm) than for controls (4.0 ± 2.3 mm). In addition, the perturbation time for the flat foot was significantly longer (P< 0.05) for the sprained group (2.2 ± 0.4 sec) than for controls (1.8 ± 0.5 sec). However, there was a higher (P< 0.05) failure rate among the sprained group for both the perturbation test with the foot flat and for baseline oscillation on the demi-pointe than among the controls. Conclusions: Our findings demonstrate altered sensorimotor control in chronically unstable ankles. Those sprainers who successfully completed the tasks “braced” the ankle, allowing a small range of oscillation. The increased perturbation time in the sprained group may reflect a deficit in either detection of inversion movements, peroneal muscle response, or both

Sporting injuries around the ankle vary from simple sprains that will resolve spontaneously within a few days to severe injuries which may never fully recover and may threaten the career of a professional athlete. Some of these injuries can be easily overlooked altogether or misdiagnosed with potentially devastating effects on future performance. In this review article, we cover some of the common and important sporting injuries involving the ankle including updates on their management and outcomes. Cite this article: Bone Joint J 2016;98-B:874–83

Summary. Nearly one-third of patients in this series with an ACL rupture requiring reconstruction had evidence of MPFL injury. This should be considered when patients are seen, and when MRI scans are reviewed/reported. Introduction. The Medial Patello-Femoral Ligament (MPFL) is the largest component of the medial parapatellar ligamentous complex. The senior surgeon felt that there was an anecdotally high rate of MPFL injury amongst his patients undergoing Anterior Cruciate Ligament (ACL) repair, but no discussion of this in the present literature. Method. A literature search was performed; although there were both scanty radiographic and anatomical studies of the MPFL, we found no literature looking at ACL and MPFL concurrent injury rates. The Magnetic Resonance Imaging (MRI) scans of fifty consecutive ACL reconstruction patients were retrospectively reviewed. Two independent radiologists were asked to review the scans looking specifically for evidence of MPFL rupture or Injury. The degree of injury was rated as rupture or by degree of sprain as applicable. One patient was excluded due to motion artefact limiting certainty. Results. Of the remaining forty-nine patients, 35 (71%) were intact, but fourteen (29%) showed evidence of injury. Five (10%) had a low-grade sprain, six (12%) had high-grade sprain, and three (6%) had complete rupture. The radiologists also noted that there was some variation in scanning protocols, and those with fat suppressed scans had better diagnostic value; this offered an opportunity to change the scanning practice. Conclusion. Nearly one-third of patients in this series with an ACL rupture requiring reconstruction had evidence of MPFL injury. This should be considered when patients are seen, and when MRI scans are reviewed/reported. Further, we would suggest that fat suppression sequences are included as standard to improve imaging quality

Objectives: Nonsteroid antiinflamatory drugs have been widely used and recommended for ankle sprains despite the fact that they are also known to lead significant adverse effects especially to the gastrointestinal system. The aim of this study is to assess the efficacy of acetaminophen in comparison with diclofenac sodium. Patients and Methods: In this prospective, double blinded, parallel group study, one hundred patients suffering from first or second degree lateral ankle sprain within 48 hours of administration were comprised. Patients with bilateral injury, ipsilateral knee injury, trird degree sprain, previous sprain within 6 months and ankle pain less than 45 according to visuel analogue score (VAS) were excluded. In addition; history including gastrointestinal, renal or hepatic disease was the reason for exclusion. Prior to enrollment cases underwent physical examination. Patients rated pain on a 100 VAS, representing 0 no pain, 100 maximal pain. After enrollment patients were randomized (1:1); diclofenac sodium 150 mg/day or acetaminophen 1500 mg/day for 5 days. Patients tretaed by diclofenac sodium were called as group I and the others were group II. In addition; cases were prescribed other intervention modalities as RICE (rest, ice, compression, elevation) and crutches. Clinical assessments were carried out at baseline; on second, tenth days and sixth weeks (end of study). In each visit, VAS and adverse effects of medication were questioned. Results: The mean VAS of the GI and GII at the first visit were 81, 82.3 respectively. These scores decreased to 20.7, 9.9, 4.6 and 11.9, 6.3, 3 at the second, tenth days and last examination. Similar reductions in pain were observed at the last visit (p> 0.05) in both groups. However; cases treated by acetaminophen showed accelerated decrease in VAS at day 2 and 10 in comparison with GI (p< 0.05). Regarding the ankle ROM there was similar increase in both groups (38.9°, 36.9°) respectively. There was no significant difference between groups with regard to ankle ROM at the last control (p> 0.05). The incidence of gastrointestinal adverse effects of GI was much more than GII. However there was no significant difference (p> 0.05). Conclusion: It was concluded that diclofenac sodium and acetaminophen are effective and well tolarated short term treatment alternatives for acute ankle injuries

Diagnosis. a. History and exam. i. True Lisfranc fracture dislocations are NOT difficult to diagnose. b. Midfoot sprains or subtle injuries. i. These are DIFFICULT to diagnose. - subtle x-ray findings with minimal displacement. i) Exam: - be “suspicious” of midfoot sprains. - TMT tenderness, swelling. - inability to WB. ii) Mechanism of injury:. - indirect twisting injury (athletic). - crush injury of the foot (trauma). - axial forefoot loading (dancers, jumpers). iii) Investigations:. - X-rays usually normal or subtle widening. need to assess all 3 views in detail. standing AP compare to the other side. -Stress x-rays: - if clinical symptoms indicate - severe injury + pain but x-ray looks normal. - MRI useful for anatomic/instability correlation. - CT scan good for subtle injuries/fractures and displacement. - Bone scan positive in subacute/chronic pain situation. Treatment. a) Surgical Indications. i) Any displacement/positive stress xrays/test. ii) Surgical technique. - open reduction or closed and percutaneus fixation. - anatomic reduction essential. - NWB period up to 6 weeks. - WB with protection for another 4-6 weeks. iii. Screw vs tightrope fixation. iv. Hardware removal. b) Non-operative. i) Stable non-displaced sprain (need to make sure this is stable, ie stress views). - 6 to 8 weeks NWB. - expect prolonged recovery up to 6 months with. proper treatment. Controversial Issues:. a. Do all injuries with mild displacement have to be fixed operatively?. b. Arthrodesis vs fixation for soft tissue lisfranc with mild displacement?. c. Arthrodesis vs fixation subacute or chronic presentation?. d. Hardware removal?

Introduction and Objectives: The aim of this study is to evaluate the results of the technique described by Ahlgren and Larsson in 1989, presenting our experience with 7 patients. Materials and Methods: A retrospective study was conducted on the clinical records of 7 adolescents treated in our center beginning in 1991 using the technique described by Ahlgren and Larsson. There were 3 males and 4 females, ranging in age from 13 to 16.5 years (average: 14 years 10 months). All subjects had a history of repeated ankle sprains for 2 to 5 years before surgery. In all cases there was painful instability of the ankle which significantly limited physical activity. In 4 cases, symptoms were present even when walking on level ground. On clinical examination, 3 cases showed significant instability under varus stress, 3 others had moderate instability, and one case had mild instability. Surgical technique was similar in all cases and involved creating a periosteal flap with a distal anterior base, including the fibulotalar and fibulocalcaneal ligaments, which was sutured with tension to the fibula. In 3 cases, this was done with the help of Mitek metal hooks. In 5 of 7 cases, an ossicle of the fibular malleolus visible on the radiographs was removed. Duration of surgery ranged from 30 to 60 minutes, with a mean of 40 minutes. Postoperative immobilisation consisted of a plaster cast used for an average of 45 days, after which time patients progressively returned to normal physical activities. Patients were advised to use an ankle brace. Average follow-up time was 35 months, with a range of 13 to 72 months. Results: In 5 patients, a subjective improvement in ankle stability was found on examination. Only in one case was there a significant reduction in radiographic instability when the tibiotalar joint was moved from 20° to 8°. One patient developed a superficial infection of the surgical wound which resolved with antibiotic treatment. Two patients suffered sprains within the first year after intervention, but there were no further sprains, and the injuries did not seem to affect the final outcome. However, the outcome of one of these was considered to be only fair due to occasional mild pain which did not limit physical activity. Two cases had poor outcomes due to frequent pain which limited physical activity postoperatively for 2 and 6 years, respectively. However, neither patient had repeat sprains during this period. The remaining 4 cases were considered to have had good results, as the patients were totally asymptomatic and without any limitation of physical activity. Discussion and Conclusions: This simple, non-aggressive method is an attractive option for use in adolescents. We therefore conclude that more studies are needed to validate its effectiveness

Introduction. The ankle cartilage has an important function in walking movements, mainly in sports; for active young people, between 20 and 30 years old, the incidence of osteochondral lesions is more frequent. They are also more frequent in men, affecting around 21,000 patients per year in USA with 6.5% of ankle injuries generating osteochondral lesions. The lesion is a result of ankle sprain and is most frequently found in the medial location, in 53% of cases. The main objective of this work was to develop an experimental and finite element models to study the effect of the ankle osteochondral lesion on the cartilage behavior. Materials and Methods. The right ankle joint was reconstructed from an axial CT scan presenting an osteochondral lesion in the medial position with 8mm diameter in size. An experimental model was developed, to analyze the strains and influence of lesion size and location similar to the patient. The experimental model includes two cartilages constructed by Polyjet™ 3D printing from rubber material (young modulus similar to cartilage) and bone structures from a rigid polymer. The cartilage was instrumented with two rosettes in the medial and lateral regions, near the osteochondral region. The fluid considered was water at room temperature and the experimental test was run at 1mm/s. The Finite element model (FE) includes all the components considered in the experimental apparatus and was assigned the material properties of bone as isotropic and linear elastic materials; and the cartilage the same properties of rubber material. The fluid was simulated as hyper-elastic one with a Mooney-Rivlin behavior, with constants c1=0.07506 and c2=0.00834MPa. The load applied was 680N in three positions, 15º extension, neutral and 10º flexion. Results. The experimental strain measured in the cartilage in the rosettes presents similar behavior in all experiments and repetitions. The maximum value observed near the osteochondral lesion was 3014(±5.6)µε in comparison with the intact condition it was 468 (±1.95)µε. The osteochondral lesion increases the strains around 6.5 times and the synovial liquid reduces the intensity of strain distribution. The numerical model presents a good correlation with the experiments (R2 0.944), but the FE model underestimates the values. Discussion and conclusion. As a first conclusion, the size of the osteochondral lesion is important for the strains developed in cartilage. The size of lesion greater than 10mm is critical for the strains concentration. The synovial fluid present an important aspect in the strains measured, it reduces the strains in the external surface of cartilage and induces an increase in the lower part. This phenomenon should be addressed in more studies to evaluate this effect

The October 2014 Foot & Ankle Roundup360 looks at: multilayer compression bandaging superior for post-traumatic ankle oedema; compression stockings for ankle fractures; weight bearing ok in Achilles tendon ruptures; MRI findings can predict ankle sprain symptoms; salvage for malreduced ankle fractures; locking fibular plates are more expensive; is fixation better early or late in pilon fractures?; and calcaneal fracture fixation not for subtalar arthropathy

Purpose: A prospective study was conducted in 160 children presenting varus trauma of the ankle. The purpose of the study was to validate the Ottawa ankle rules in children. Application of the Ottawa rules can reduce the number of x-rays by 25% but little work has been reported concerning their validation (Chande 1995). Material and methods: One hundred sixty children, 71 boys and 89 girls, mean age eleven years three months (range 3 – 15 years) were included in this study conducted between February 2001 and December 2001. Clinical presentations with an obvious diagnosis of ankle fracture were excluded (six patients). Epidemiological and clinical data and the initial Ottawa criteria were recorded on a data sheet with a specific number of assigned items. A standard radiographic work-up with an anteroposterior, lateral and oblique view of the ankle was obtained in all cases. All patients were seen at a second consultation on day 8 by another physician to confirm diagnosis. The x-rays were read three times: by the emergency care physician, and by a second physician and a paediatric orthopaedic surgeon at the 8-day consultation. Results: Diagnosis which were confirmed were: benign sprains (BS) (n=71), moderately severe sprains (MS) (n=47), severe sprains (SS) (n=2), type I epiphyseal detachment (ED) (n=21), fractures (n=13) (8 fifth metatarsal, 1 triple fracture line, 1 medial malleolus, 2 lateral malleolus, 1 tarsal scaphoid). For the Ottawa criteria, ankles positive for pain and at least one other criterion were: 64/77 BS, 43/47 MS, 2/2 SS, 21/21 DE and 13/13 fractures. All fractures were diagnosed at the first exam or at the 8-day exam. Discussion: Based on our findings, the clinical Ottawa rules cannot be considered to be validated for children. Using these rules, x-rays would have been performed in 143 patients to identify 13 fractures that were not clinically obvious. Because the Ottawa rules are insufficiently specific for children, we recommend, like Brooks (1981) to use more rigorous clinical criteria for the diagnosis of ankle trauma in children. The diagnostic criteria used in this study enabled correct first intention diagnosis in 129 patients with trauma. We propose ordering x-rays only for children with signs of moderate or severe sprain or pain in zone C (base of the fifth metatarsal: 8/8) or E (medial border of the foot: tarsal scaphoid fracture). For other cases (98/160) physical examination is sufficient. Conclusion: We do not consider the Ottawa clinical rules to be valid for varus ankle trauma in children. We propose clinical criteria which can limit the number of x-ray work-ups by 60% in children with this type of trauma

We investigated a new method of stress radiography of the subtalar joints using forced maximum dorsiflexion of the ankle in a supinated position. We measured transposition of the lateral process of the talus at the posterior subtalar joint in lateral views of normal amputated ankles, normal control subjects and patients with recurrent ankle sprains. The mean displacement in the control groups (n = 36) was 29.9%, significantly different from the 43.0% in patients with recurrent ankle sprains (n = 24). In the amputated specimens with intact ligaments movement was similar to that in normal subjects. Section of the calcaneofibular and the interosseous ligaments allowed much the same movement as in patients with recurrent ankle sprains. The new method is simple and useful for detecting subtalar instability

Following ankle sprain, there can be many causes of disability including ligament injuries, soft tissue or bony impingement, Peroneal tendon tears, osteochondral defects (OCD), synovitis and Osteoarthritis (OA). Aim: To assess the use of Ankle MRI in clinical decision-making in patients with pain and/or chronic instability following ankle sprains. Method: A retrospective case note review was undertaken for all ankle scopes performed and all Ankle MRI ordered by a single surgeon (AOA) over a three-year period (April 2004 – April 2007). Results: During this period 54 Ankle arthroscopies were performed. 24 had pre op MRI scans (16 ordered by AOA and 8 by others who then referred the patient) and 30 had no MRI. 8 case notes were not available. In 43 of the 46 available notes the patients presented with either chronic ankle pain or instability following ankle sprain. 32 had Anterolateral soft tissue impingement on arthroscopy. Of these 24 had MRI scans with only 3 reporting a soft tissue impingement. 13 patients had lateral ligament reconstruction. All 13 of these patients showed signs of instability on examination under anaesthesia (EUA). Of these 9 had MRI scans with 4 reporting a ligamentous injury. Five other patients had MRI scans that showed a lateral ligament injury but had a normal EUA and did not undergo a ligament reconstruction. 10 patients had moderate to severe OA on arthroscopy of the ankle. Of these 4 had MRI scans with 2 reporting OA changes but 2 reported as OCD. Conclusion: Analysing the available data suggests that the indication to perform an arthroscopy is not dependent on the results of the MRI scan but is a clinical one. The decision to reconstruct/repair the lateral ligament complex is a clinical one dependent on patient symptom and the EUA findings

The April 2013 Trauma Roundup. 360 . looks at: ankle sprains; paediatric knee haemarthroses; evidence to support a belief; ‘Moonboot’ saves the day; pamphlets and outcomes; poor gait in pilons; lactate and surgical timing; and marginal results with marginal impaction

Purpose of the study: Ankle sprains constitute a serious public health problem with nearly 6000 consultations daily in France. The prognosis is generally good if a precise clinical diagnosis can be established and appropriate treatment undertaken. The purpose of this study was to ascertain the pertinence of the initial physical examination which determines the treatment by correlating it with the results of a high-resolution ultrasound examination. Material and methods: This prospective study included 23 patients, mean age 30.7 years, who were followed regularly for three months. A total of 154 ultrasound explorations were performed. The initial treatment for these patients who consulted a hospital emergency room for ankle trauma was established on the basis of the Ottawa criteria. The ankles were examined by a senior physician and an ultrasonographic exploration was performed 3.9 days on average after the first consultation in the emergency room. Standard protocols were used for the physical examination and for the ultrasonography. Results: The initial results confirmed a lesion of the lateral collateral ligament in 91% of cases with an initial tear of the anterior talofibular ligament in half of the cases and a injury to the calcaneofibular ligament in one out of five cases. One quarter of the patients had an isolated lesion. One out of ten presented a lesion of the syndesmosis and one out of three lesions of the fibular tendons. The standard ankle examination performed by the senior physician established correct diagnosis of the precise lesion in 80% of the cases. Discussion: Lesions of the mid food and of the syndesmosis are diagnosed clinically, ultrasonography is not contributive. The stage of the initial lesion was compared with the stage at three months: in 7 out of 10 cases, the anterior talofibular and the calcaneofibular ligaments had healed correctly. Physical examination is essential but ultrasonography provides certain complementary information at a time when the physical examination can be hindered by the pain and potentially the lesser experience of emergency room examinators. Conclusion: In light of the evidence provided by this study, it can be confirmed that the initial diagnosis of ankle sprain established in an emergency room setting can be corrected by a physical examination performed by an experienced clinician. At the present time, it is not possible to demonstrate the specific contribution of ultrasonography for the management of ankle sprains. This would require a prospective study over a longer period and should be designed to demonstrate the relationship between injury of the fibular tendons and ankle stability

Aim:. Ankle sprains are one of the most common sports injuries. Around 10–20 % of the acute ankle sprains may lead to the sequelae of chronic ankle instability. Around 15–35% of the patients have residual pain following successful lateral ligament reconstruction. One of the reasons suggested for the persistent symptoms following lateral ligament reconstruction has been the presence of intra-articular pathology. Methods and materials:. We performed ankle arthroscopy on all patients undergoing the modified Brostrom repair and compared patients with associated intra-articular pathology to those without any intra-articular pathology. Results:. A total of 35 patients underwent the modified Brostrom procedure during the study period. 11/25 patients were found to have associated intra-articular pathology. The average age for both the groups was 33 years. The average follow-up duration was 75 months and 71 months for the intra-articular pathology group and the normal articular groups respectively. The difference in the SAFAS (Sports athlete foot and ankle score) was statistically better in the group without any intra-articular pathology (93.7 compared to 71.6, p-value < 0.05). Conclusions:. The patients who have an associated intra-articular pathology whilst undergoing the stabilisation of lateral ligament instability of the ankle have a slightly poorer outcome compared to those without any intra-articular pathology. Secondly, the SAFAS scoring system seems to overcome the ceiling effect seen in other scoring systems when used for the athletic population

This study concerns an epidemiological analysis of foot and ankle injuries during the Athens Olympic Games 2004. An epidemiological survey was used to analyse injuries in all sport tournaments over the period of the Games. During the Athens Olympic Games 2004 in the period from August 1st to September 1st, 624 patients presented to the Foot and Ankle Department for treatment. The mean age of athletes was 24 years (range 21 to 32). Among the patients there were more males, 358 (58%) than females, 266 (42%). In 525 (84.1%) patients there was only a soft tissue injury and in 99 (15.9%) patients there was bone involvement. Regarding specific diagnoses, tendinitis was the most common reason for a visit, followed by ankle sprains, nail infections/injuries, lesser toes sprains, and stress fractures. Sixty-nine (11%) required emergency transfer to the hospital. Our experience from the Athens Olympic Games will inform the development of public health surveillance systems for future Olympic Games, as well as other similar mass events

The aim of this study was to describe the epidemiology of elite youth soccer knee injuries from prospective data collected from forty-one English FA Football Academies over a 5 year period. 12306 players were registered from U9 to the U16 age category. We studied the incidence of injuries around the knee with particular emphasis upon those causing greater than 28 days time off sport. There were 609 knee injuries with a mean incidence of 0.71 knee injuries per player per year and a median of 17 training days and 2 matches missed per knee injury. Increased injury rates were seen in older players, in competitive situations and in the latter stages of each half of play. Peaks in injury numbers were seen in early season and subsequent to the winter break. Sprain was the most common diagnosis with the Medial Collateral ligament affected in 23.2% of cases. 609 injuries met the UEFA Model criteria for major injury. In total 60,091 training days and 5,272 match appearances were lost through knee injury. Knee injuries are common in elite level youth footballers and are often severe in nature, resulting in large amounts of training time lost to injury. Diagnosis of ligament sprain is common leading to prolonged time off, and may mask more serious pathology or inappropriate management

Aims

Due to the recent rapid expansion of scooter sharing companies, there has been a dramatic increase in the number of electric scooter (e-scooter) injuries. Our purpose was to conduct a systematic review to characterize the demographic characteristics, most common injuries, and management of patients injured from electric scooters.

Consecutive patients with a confirmed rupture of at least one of the lateral ligaments of the ankle were randomly assigned to receive either operative or functional treatment. They were evaluated at a median of 8 years (6 to 11). In total, 370 patients were included. Follow-up was available for 317 (86%). Fewer patients allocated to operative treatment reported residual pain compared with those who had been allocated to functional treatment (16% versus 25%, RR 0.64, CI 041 to 1.0). Fewer surgically-treated patients reported symptoms of giving way (20% versus 32%, RR 0.62, CI 0.42 to 0.92) and recurrent sprains (22% versus 34%, RR 0.66, CI 0.45 to 0.94). The anterior drawer test was less frequently positive in surgically-treated patients (30% versus 54%, RR 0.54, CI 0.41 to 0.72). The median Povacz score was significantly higher in the operative group (26 versus 22, p < 0.001). Compared with functional treatment, operative treatment gives a better long-term outcome in terms of residual pain, recurrent sprains and stability

Purpose: We report a series of 46 cases of subtal instability associated or not with tibiotarsal lesions treated by Castaing ligamentoplasty between 1988 and 1999. Material and methods: Preoperatively, symptoms were: instability, twisted ankle, recurrent ankle sprains, pain. A tarsal sinus syndrome was found in 39%. MRI was performed in all 46 patients and revealed ligamentary lesions in all case. Outcome was assessed with the Kitoaka score. Results: At mean 5.7 years follow-up instability had resolved in 80% of the ankles. Total pain relief was noted in 63%. Physical examination demonstrated reduced motion of the subtalar joint with inversion in 43% ranging from 50% to 70% compared with healthy side, but without significant functional impact. Radiographic signs of early-stage degeneration were found in three patients. Overall outcome was very good in 82%, fair in 11%, and poor in 7%. The index of patient satisfaction was 87%. Discussion: This series showed a correlation between body mass index greater than 26 or constitutional laxity and fair or poor results. Furthermore, longer time between the first sprain and surgical management of the residual instability led to less satisfactory final outcome. Comparison with other ligamentoplasty techniques showed similar results. Conclusion: The Castaign procedure provides results similar to other ligamentoplasty techniques. Direct repair of the subtalar ligaments should however be preferred as the first-intention procedure, reserving Castaign ligamentoplasty for cases of failed repair

Summary. Movement analysis (IMA) and activity monitoring (AM) using a body-fixed inertia-sensor can discriminate patients with ankle injuries from controls and between patients of different pathology or post-injury time. Weak correlations with PROMs show its added value in objectifying outcome assessment. Introduction. Ankle injuries often result in residual complaints calling for objective methods to score outcome alongside subjective patient-reported outcome measures (PROMs). Inertial motion analysis (IMA) and activity monitoring (AM) using a body-fixed sensor have shown clinical validity in patients suffering knee, hip and spine complaints. This study investigates the feasibility of IMA and AM 1) to differentiate patients suffering ankle injuries from healthy controls, 2) to compare different ankle injuries, 3) to monitor ankle patients during recovery. Methods. 32 patients suffering ankle problems (ankle sprain, n=17, 42 ±26yrs; operatively managed ankle fracture, n=15, 44 ±17yrs) during short-term recovery (6weeks to 3months post-trauma) were compared to 22 matched healthy controls (41 ±13yrs). Function was measured using IMA: Gait, Sit-Stand (STS) and 10s one-leg Balance test (OLB) were performed while wearing a 3D inertia-sensor at the lower back. Physical activity was measured during 4 successive days using a 3D accelerometer (AM), attached at the upper leg. Validated algorithms were used to derive motion parameters (e.g. speed for gait, bending angle for STS, sway area for OLB, # steps for AM). Moreover three ankle specific questionnaires were completed: Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ), Foot and Ankle Ability Measure (FAAM), AOFAS ankle-hindfoot score. Data was analysed using paired t-tests, one-way ANOVA and Pearson's r. Results. Both patient groups performed worse in function (IMA), activity (AM) and scales (PROM). Even at 3 months mean walking speed (−26%) and cadence (−9%) were slower while pelvic obliquity during ST (+18%) and sway during OLB (+230%) was higher than in controls (p<0.05). Activity was less regarding step/day (−31%) and sit-stand transfers (−11%, p<0.05). Also PROMs were significantly worse in patients (range 17–37%). Comparing in-between patients, significant differences were found in PROMs and function (IMA) with fracture patients walking slower (−30%) or showing more sway during one-legged balance (+250%). Mean activity scores (steps, bouts, cadence) were also less for fractures (p>0.05). During recovery, PROMs improved significantly, while function (IMA) and activity (AM) only showed small or selective improvements (e.g. 8° reduction in bending angle during ST, 20% increase in cadence). Only weak to moderate correlations were found between PROM, IMA (r-range: 0.32–0.79) and AM parameters (r-range: 0.31–0.71). Discussion & Conclusion. Function, physical activity and PROMs were impaired in patients with ankle injuries compared to healthy subjects, with the fracture group performing worse on IMA and PROMs than the sprain group. In this first study ever to measure activity in ankle patients, it was shown that e.g. fracture patients walk ca. half as many steps and bouts as age-matched controls even though at 6weeks they were unable to walk 20m without walking aids (floor effect of IMA function test). The lack of improvements in IMA and AM during recovery while PROMs improved significantly, together with the few and only weak-to-moderate correlations between PROMs, IMA and AM shows that subjective and objective recovery differ and highlight the added value of IMA and AM for objectifying routine clinical outcome assessment

Introduction: Ankle sprains are among the most common injuries in sports and recreational activities. 10 to 40% of the acute ankle sprains lead to chronic ankle instability (CAI), which can be divided into its mechanical and its functional division. The clinical-orthopaedic diagnosis of mechanical ankle instability (MAI) has been well established, whereas the etiology of the functional ankle instability (FAI) is still not objectively allocatable. The aim of this study was to identify neuromuscular patterns in lower leg muscles to objectively describe the FAI. Methods: 15 patients suffering from unilateral CAI (mean age, 35.5 years) since 2.4 years (1–9 years) were examined. The patients were evaluated etiologically and clinically (VAS pain score, AOFAS Ankle Score, calf circumference, and SF-36). Electromyographic (EMG) measurements of surface EMG with determination of mean EMG frequency and intensity by wavelet transformation were taken synchronously with dynamic stabilometry measurements. Four lower leg muscles were detected: tibialis anterior (TA), gastrocnemius medialis (GM), soleus (SO), and peroneus longus (PL) muscle. 15 healthy subjects were tested identically. Results: Patients showed higher stability indices, higher VAS score, and lower AOFAS Ankle Score. The mean EMG frequency was significantly lower for the PL (pathologic leg, 138.3 Hz; normal leg, 158.3 Hz, p< 0.001). Lower mean EMG intensity was found in the pathologic PL and GM. The mean EMG frequency of the TA was lower in the patient group, its intensity higher. Discusssion and conclusion: Patients suffering CAI demonstrate weakened stability and impaired life quality. Neuromuscular patterns of the GM, PL and TA lead evidently to an objective etiology of the functional ankle instability. EMG patterns of four lower leg muscles indicate chronic changes in muscle morphology, such as degradation of type-II muscle fibres or modified velocity of motor unit action potentials. Accurate prevention and rehabilitation may compensate a MAI with a sufficient functional potential of lower leg muscles. This may also avoid operative treatment of MAI. The present study evidences the etiology of the FAI with objective parameters and indicates chronic changes in muscle morphology within CAI-Patients

Purpose: Ankle sprains are among the most common injuries in sports and recreational activities. 10 to 40% of the acute ankle sprains lead to chronic ankle instability (CAI), which can be divided into its mechanical and its functional division. The clinical-orthopaedic diagnosis of mechanical ankle instability (MAI) has been well established, whereas the etiology of the functional ankle instability (FAI) is still not objectively allocatable. The aim of this study was to identify neuromuscular patterns in lower leg muscles to objectively describe the FAI. Method: 15 patients suffering from unilateral CAI (mean age, 35.5 years) since 2.4 years (1–9 years) were examined. The patients were evaluated etiologically and clinically (VAS pain score, AOFAS Ankle Score, calf circumference, and SF-36). Electromyographic (EMG) measurements of surface EMG with determination of mean EMG frequency and intensity by wavelet transformation were taken synchronously with dynamic stabilometry measurements. Four lower leg muscles were detected: tibialis anterior (TA), gastrocnemius medialis (GM), soleus (SO), and peroneus longus (PL) muscle. 15 healthy subjects were tested identically. Results: Patients showed higher stability indices, higher VAS score, and lower AOFAS Ankle Score. The mean EMG frequency was significantly lower for the PL (pathologic leg, 138.3 Hz; normal leg, 158.3 Hz, p< 0.001). Lower mean EMG intensity was found in the pathologic PL and GM. The mean EMG frequency of the TA was lower in the patient group, its intensity higher. Conclusion: Patients suffering CAI demonstrate weakened stability and impaired life quality. Neuromuscular patterns of the GM, PL and TA lead evidently to an objective etiology of the functional ankle instability. EMG patterns of four lower leg muscles indicate chronic changes in muscle morphology, such as degradation of type-II muscle fibres or modified velocity of motor unit action potentials. Accurate prevention and rehabilitation may compensate a MAI with a sufficient functional potential of lower leg muscles. This may also avoid operative treatment of MAI. The present study evidences the etiology of the FAI with objective parameters and indicates chronic changes in muscle morphology within CAI-Patients

Purpose: To document the recovery of knee function following Medial Collateral Ligament (MCL) injury of the knee. Methods and Results A cohort of 38 consecutive patients with MCL injuries were followed prospectively from the time of injury for a period of one year. There were 13 grade I MCL sprains and 25 grade II sprains. Twelve patients had a concomitant ACL tear. Patients were treated in a hinged knee brace with full extension and 90 degrees of knee flexion for 6 weeks from the date of injury. All patients had an identical rehabilitation programme. Clinical outcome was assessed using two standard functional knee scores (International Knee Documentation Committee (IKDC) score and Knee Outcome Orthopaedic Score (KOOS)). Quadriceps and hamstring muscle function was tested isokinetically using a dynamometer. Outcome assessments were carried out at 2 weeks, 6 weeks, 3 months, 6 months and 1 year. At 2 weeks the average range of motion (ROM) difference from the normal side was 31%. Twenty-five patients (66%) restored a functional range of motion (5–120 degrees) by 6 weeks. Thirty-five patients (92%) had a normal ROM by 3 months. Peak torque, average power and total work of quadriceps and hamstring muscle groups were normal in 4 patients (11%) at 6 weeks. At 3 months 11 patients (29%) had restored normal muscle function. At 6 months 46% of patients had normal muscle function. At 1 year 11 patients (29%) still had abnormalities of muscle function on isokinetic testing. Conclusions: Patients with MCL injuries can be advised that range of motion can be expected to return to normal in the majority of cases by 3 months but muscle function recovers more slowly over 12 months following injury

Aims

The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Additionally, we evaluated the rate of graft incorporation and identified associated predisposing factors using CT scan.

Aims

The aim of this study was to describe the introduction of a virtual pathway for the management of patients with a suspected fracture of the scaphoid, and to report patient-reported outcome measures (PROMs) and satisfaction following treatment using this service.

Ankle sprains are very common, and usually tear or partly tear one or more of the ligaments on the outer side of the ankle. The ankle joint is only designed to move up and down, whereas there is another joint immediately below the ankle joint, called the subtalar joint, which is designed to do the tilting in and out movement. If the foot tilts over too far, the subtalar joint reaches the end of its movement and then the ankle ligaments stretch and tear. It is possible that variations of subtalar range of movement may contribute to ankle sprains or symptoms of weakness or instability. In particular, if the subtalar joint is unusually restricted in its movement, then the foot does not have to tilt far before the lateral ligaments tear. If on the other hand the subtalar joint is particularly mobile and has excessive movement, then the foot may go right over without actually tearing ligaments and feel insecure or unstable simply as a result of abnormal excessive movement. Recent studies have demonstrated what we have always suspected, that clinical examination and assessment of subtalar range of movement is highly unreliable. In order to accurately assess whether your subtalar range of movement is unusually restricted or excessive, the only standard and accurate method to date has been to obtain a CT scan. We are now undertaking a study to establish whether plain xrays with a small metal clamp applied to the heel might not be a simpler, cheaper, quicker and equally reliable method of assessment of subtalar movement. If you would like to know if your subtalar movement might be a contributing factor to either stiffness or insecurity of your ankle, we invite you to be examined clinically, by plain xrays at SPORTSMED•SA, and by a CT scan at Jones & Partners Radiology at Burnside. The xray and CT investigations would be bulk billed under Medicare so that you would not incur any personal cost and the information could well be helpful in assessing your ankle problem, or at least be reassuring that the subtalar joint has a normal range of movement. The investigations can be arranged through your treating doctor, physiotherapist or podiatrist or by contacting Dr Roger Paterson, Foot and Ankle Surgeon, or Mr Stephen Landers, his Research Assistant, on Ph: 8362 7788. The CT scan would be a very limited investigation resulting in minimum radiation exposure, comparable to the normal xrays. Further information on what is involved in having a CT scan is attached. Neither the CT scan nor the plain xrays should cause any more than minor discomfort as the foot is tilted through its full range of movement, or from the padded pressure of the G clamp. SPORTSMED•SA remains committed to excellence in treating active people of all ages, and through these investigations, we plan to further enhance the quality of assessment and care of people who suffer ankle problems

Aims

The underlying natural history of suspected scaphoid fractures (SSFs) is unclear and assumed poor. There is an urgent requirement to develop the literature around SSFs to quantify the actual prevalence of intervention following SSF. Defining the risk of intervention following SSF may influence the need for widespread surveillance and screening of SSF injuries, and could influence medicolegal actions around missed scaphoid fractures.

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The aim of this retrospective cohort study was to assess and investigate the safety and efficacy of using a distal tibial osteotomy compared to proximal osteotomy for limb lengthening in children.

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The Vantage Total Ankle System is a fourth-generation low-profile fixed-bearing implant that has been available since 2016. We aimed to describe our early experience with this implant.

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Machine-learning (ML) prediction models in orthopaedic trauma hold great promise in assisting clinicians in various tasks, such as personalized risk stratification. However, an overview of current applications and critical appraisal to peer-reviewed guidelines is lacking. The objectives of this study are to 1) provide an overview of current ML prediction models in orthopaedic trauma; 2) evaluate the completeness of reporting following the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement; and 3) assess the risk of bias following the Prediction model Risk Of Bias Assessment Tool (PROBAST) tool.

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To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-β, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration.

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The aim of this study was to screen the entire genome for genetic markers associated with risk for anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injury.

Surfing is a popular UK water-sport. Recommendations for protective gear are based on studies abroad from trauma from large waves and reef breaks which may not be relevant in the UK. This study assesses the aetiology of UK surfing injuries in order to assist treatment and provide formative recommendations on protective equipment. Data was collected from UK surf clubs via an online survey. 130 individuals reported 335 injuries. M:F ratio 85:45, median age 28 (range 17–65). Head injuries were the most common (24%) followed by foot and ankle (19%). Surfers collided most often with their own boards (31%) followed by rocks/coral (15%), the sea (11%) and other surf boards (10%). Lacerations were the commonest injury (31%); followed by bruises/ black-eyes (24%) and joint/ligament sprains (15%). Concussions (5%), fractures (3%) and teeth injuries (1%) were rare. Less than 1/3 of all injuries required professional medical attention, 2 required operative intervention. Surfing injuries in the UK are common but usually minor. Serious head injuries (fractures and concussions) are rare. There is insufficient evidence to warrant the routine use of protective helmets whilst surfing in the UK, although protective head and foot gear may be considered when surfing the rarer reef/ rock breaks

Stand-up paddle-boarding (SUP) is an increasingly popular water sport. To our knowledge no published data exists regarding injuries sustained whilst participating in this new sport. This study investigates the frequency, pattern, and mechanism of SUP injuries. Data was collected from UK SUP and surfing clubs via an online survey. Completed surveys were obtained from 31 paddle-boarders (M:F 25:6, median age 27, range 21–65) reporting 18 injuries and 130 surfers reporting 4 SUP-related injuries. 50% of paddle-boarders reported an injury. All SUP injuries were sustained when surfing waves, rather than paddling on calm water. Sprains accounted for 50%, lacerations 22%, contusions 17% and fractures 5%. 78% of injuries were to the lower extremity, and 17% to the head and neck. 17% sustained recurrent twisting injuries, two suffering recurrent knee injuries and one suffering recurrent ankle injuries, resulting in sprains. 17% of injuries resulted from contact with one's own paddle-board, 17% from another paddle-board, and 5% from the sea floor. Despite surfer concerns regarding paddle-board mass and control, paddle-board related injuries only accounted for 1% of the 335 injuries reported by surfers. SUP is relatively safe in calm water conditions, with a similar injury pattern to surfers when used in waves

Osteochondral lesions (OCLs) occur in up to 70% of sprains and fractures involving the ankle. Atraumatic aetiologies have also been described. Techniques such as microfracture, and replacement strategies such as autologous osteochondral transplantation, or autologous chondrocyte implantation are the major forms of surgical treatment. Current literature suggests that microfracture is indicated for lesions up to 15 mm in diameter, with replacement strategies indicated for larger or cystic lesions. Short- and medium-term results have been reported, where concerns over potential deterioration of fibrocartilage leads to a need for long-term evaluation. . Biological augmentation may also be used in the treatment of OCLs, as they potentially enhance the biological environment for a natural healing response. Further research is required to establish the critical size of defect, beyond which replacement strategies should be used, as well as the most appropriate use of biological augmentation. This paper reviews the current evidence for surgical management and use of biological adjuncts for treatment of osteochondral lesions of the talus. . Cite this article: Bone Joint J 2014;96-B:164–71

Aims

The primary aim of this study was to determine the rates of return to work (RTW) and sport (RTS) following a humeral shaft fracture. The secondary aim was to identify factors independently associated with failure to RTW or RTS.

Aims

The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes.

Introduction. Foot and ankle injuries are a common occurrence amongst all footballers. The aim of this study was to establish the frequency and variation of foot and ankle injuries within one English Premier League (EPL) professional football club over the course of a season and attempt to identify any factors associated with the injuries. Method. Data was collected prospectively for all foot and ankle injuries suffered by first team players over the 2008–09 and 2009–10 EPL season at one EPL club. Each player's demographics were recorded along with various factors concerning or influencing the injury including ground conditions, foot posture index score (FPIS), type of injury, ability to continue playing, recovery time, mechanism of injury and footwear type. Results. The most common injury was 5th metatarsal fracture seen in 33%. Lateral ligament sprain was seen in 28% and syndesmosis injury in 17%. The mean recovery time following 5th metatarsal fractures was 76 days. 67% of all injuries (100% of 5th metatarsal fractures) were sustained while wearing blade footwear, 17% wearing the more traditional studded footwear. Supination was the most common FPIS, present in 43%. 56% of injuries were in the dominant (kicking) side while 50% of injuries were sustained in the tackle. There were no ankle fractures observed. Conclusion. 5th metatarsal fractures are the most common foot & ankle injury amongst professional footballers, ankle fractures are relatively rare in comparison. Injuries occur more frequently with blade footwear, with supination being the most common foot posture at the time of injury

Foot pain in children is common. The reason for the pain can usually be determined from history and physical examination, but often a radiogram is necessary. The causes for painful foot can be divided into following categories:. • Trauma (Fractures, sprains, soft tissue injuries, puncture wounds, overuse syndromes). • Infections (Osteomyelitis, septic arthritis, ingrown toe-nail). • Arthritis (Degenerative, juvenile rheumatoid). • Osteochondroses (Köhler, Freiberg, Sever) • Deformities (Bunions, tarsal coalitions). • Tumors. • Others The specific treatment depends on the diagnosis and occasionally on the age of the child

1. A review of intra-articular and peri-articular fractures of the phalanges has been carried out, and the late results of such injuries have been examined. 2. These fractures usually unite by bone. 3. The results of conservative treatment by immobilisation are satisfactory in the case of mallet fractures, hyperextension sprain fractures and collateral avulsion fractures of the proximal phalanges. 4. The less satisfactory results after collateral avulsion fractures of the interphalangeal joints and avulsion fractures complicating dislocations are discussed

Acute peroneal tendon tears present as a relatively sudden onset of lateral ankle or hindfoot pain, frequently in conjunction with a traumatic episode or injury. Underlying or causative factors, including recurrent ankle sprains, hindfoot varus leading to ankle instability, or dislocating peroneal tendons may be associated and can often lead to peroneal tendon tears being overlooked as a cause of persistent lateral ankle or foot pain. Some apparently acute peroneal tendon tears may represent an acute manifestation of an underlying chronic or subclinical abnormality. The spectrum of peroneal tendinopathies includes tenosynovitis, tendinosis, subluxation or dislocation, stenosing tenosynovitis, disorders of the os peroneum, and conditions related to accessory peroneal tendons, as well as acute and chronic tendon tears. These abnormalities of the peroneal tendons may coexist, and one may lead to another, as evidenced by the significant incidence of tears in the presence of dislocating peronei and ankle instability. Suspicion of the possibility of peroneal tendon injury, coupled with careful clinical examination and appropriate investigation, allows the clinician to identify the extent of damage and to implement a successful management plan. Because peroneal tears signify a mechanical abnormality, this management often entails surgical intervention

Introduction. Coronal plane deformity can pose difficulties with balancing in Total Ankle Replacement (TAR). Current reports outline improved outcomes in the presence of varus deformity. Soft tissue balancing techniques are well described, but are limited by no link to eitiology and pathoanatomy of the deformity. Method. A prospective review of all the TAR by the senior author was performed to identify cases of pre-operative varus greater than 10°. A chart review was performed to identify aetiology, intraoperative findings, and operative techniques to achieve a balanced TAR. X-rays were examined to measure deformity and amount of correction. Volumetric rendering and segmentalisation was performed on pre- and post-CTs to identify anatomical defects, osteophyte formation, rotational and translational changes of the hindfoot joints. Results. Between January 2002 and January 2009 there were thirty-five cases from two hundred and thirty cases with varus deformity greater than 10°, with an average 17° varus angle (range 10° to 30°). Multiple sprains and instability over several years was seen in 62% of patients. Clinically, increasing varus was associated with cavovarus foot position. Incongruent deformities had intact tibial plafond. Congruent deformities had tibial defects in the anteromedial tibial plafond and associated anterolateral tibial ostephyte. Increasing deformity often had lateral fibula osteophytes and ossicles between fibula osteophyte and anterolateral talar body. In more severe cases, 3D analysis showed the talus was anteriorly displaced and internally rotated. Post operative alignment improved from 17° to 1.5°. Conclusion. Understanding the pathoanatomy of the arthritic ankle with coronal plane deformity can help plan the surgical techniques required to correct this often challenging surgical reconstruction

Introduction. Osteochondral lesions of the talus are common injuries following acute and chronic ankle sprains and fractures, the treatment strategies of which include both reparative and restorative techniques. Recently, restorative techniques (i.e., autologous osteochondral transplantation) have been become increasingly popular as a primary treatment strategy, in part due to the potential advantages of replacing “like with like” in terms of hyaline cartilage at the site of cartilage repair. The current study examines the functional results of autologous osteochondral transplantation of the talus in 72 patients. Methods. Between 2005 and 2009, 72 patients underwent autologous osteochondral transplantation under the care of the care of the senior author. The mean patient age at the time of surgery was 34.19 years (range, 16–85 years). The mean follow-up time was 28.02 months (range, 12–64 months). Patient-reported outcome measures were taken pre-operatively and at final-follow-up using the Foot and Ankle Outcome Score and Short-Form 12 general health questionnaire. Quantitative T2-mapping MRI was also performed on select patients at 1-year post-operatively. Results. The mean FAOS scores improved from 52.67 points pre-operatively to 86.19 points post-operatively (range, 71–100 points). The mean SF-12 scores also improved from 59.40 points pre-operatively to 88.63 points post-operatively (range, 52–98 points). Three patients reported donor site knee pain after surgery. Quantitative T2-mapping MRI demonstrated relaxation times that were not significantly different to those of native cartilage in both the superficial and deep halves of the repair tissue. Discussion and Conclusion. Autologous osteochondral transplantation is a reproducible and primary treatment strategy for large osteochondral lesions of the talus and provides repair tissue that is biochemically similar to that of native cartilage on quantitative T2-mapping MRI. This may ultimately allow the ankle joint to function adequately over time

Osteochondral lesions (OCL) of the talus occur in 38% of the patients with supination external rotation type IV ankle fractures and 6 % of ankle sprains. Osteoarthritis is reported subsequently in 8–48% of the ankles. Several marrow stimulation methods have been used to treat the symptomatic lesion, including arthroscopic debridement and micro fracture. Encouraging midterm results have been reported, but longterm outcome is unknown in relation to more invasive treatments such as transfer of autologous osteoarticular tissue from the knee or talus (OATS), autologous chondrocyte implantation (ACI), frozen and fresh allograft transplantation. Aim. The aim of our study was to review our long term results of arthroscopic treatment of osteochondral lesions of the talus. Materials and methods. 65 patients underwent arthroscopic treatment of the OCL between 1993 and 2000. There were 46(71%) men and 19(29%) women. The mean age at surgery was 34.2 years. The right side was affected in 43 patients and the left side in 22 patients. Results. 40/65(61.5%) patients who underwent arthroscopic treatment of the OCL were followed up. The mean follow-up was 13.1 years (9 to 18 years). The average age at final follow was 49.6 years (25–80 years). 15 (39.5%) patients reported poor, 14 (36.8%) fair, 9 (23.6%) good outcomes based on the Berndt and Harty criteria. 20/40 patients (50 %) needed further surgery. This appears a significant deterioration since this cohort were studied at 3.5 years, when the clinical results were 21.3% poor, 26.2% fair and 52.3% good, although losses to followup make exact comparison impossible. Conclusion. Arthroscopic treatment of osteochondral lesions of the talus gives medium term improvement in the majority of patients, but it appears that results deteriorate with time. Recurrence of symptoms sufficient to require further surgical intervention occurred in half the patients studied

The ‘gold standard’ for treatment of chronic ankle instability is Brostrom-Gould procedure, which is an ‘open’ surgery. Most authors recommend this type of operation even after an arthroscopic inspection of the joint. The arthroscopic methods, including thermal shrinkage, propose in the past didn’t received a widely spread support. We present a method of arthroscopic lateral ligament ‘repair’ with an anchor placed in the fibula. We used this technique on 31 consecutive patients (28 were available for follow-up). 21 patients were victims of work or traffic accidents and 3 had sport-related lesions. The patients were evaluated after a 24,5 month follow-up. The average post-op AOFAS score was 85,3 and average satisfaction was 3,77 (1 to 5). We had two ‘relapses’ (another sprain without instability on the stress XR). On 3 patients we had some wound healing problems and we had 3 lesions of the superficial peroneal nerve, one of these is persistent. One patient developed a deep vein thrombosis post operatively. With this method, we achieved good results with relatively few complications, even more considering that most of the patients were work-compensation cases. It’s a simple procedure, less ‘aggressive’ then the traditional one’s, producing an anatomical and functional repair of the lateral ligament

Introduction: Ankle sprain is one of the common presentations in Accident and Emergency. Accurate diagnosis is critical and sometime difficult without special investigation such as Magnetic Resonance Imaging (MRI) or arthroscopy. Aim: The purpose of this project was to evaluate magnetic resonance imaging (MRI) accuracy for diagnosing and defining ankle pathology. Method: Retrospective review of 36 patients who underwent both MRI and Arthroscopy. All cases were seen by single orthopaedic surgeon with special interest in foot and ankle surgery. MRI scan were reviewed by consultant radiologist at our institute. Arthroscopy was used as a standard for comparing MRI results. Sensitivity and Specificity was calculated by qualified statistician. Results: For osteochondral lesion the Sensitivity of 85.7 %, Specificity of 93.3% and Accuracy of 89.7% was noticed. Anterior and posterior tibiofibular ligament (ATFL and PTFL) pathology had a Sensitivity of 100 %, Specificity of 100% and Accuracy of 100%, while anterior inferior tibiofibular ligament pathology had a Sensitivity of 66.6 %, Specificity of 95% and Accuracy of 86.6%. Conclusion: Although MRI is a useful tool in exclusion of pathological condition its sensitivity and accuracy in diagnosing ligament injury is not encouraging

We describe three children with symptoms of damage to the attachment of an anomalous ossific centre of the lower fibular epiphysis. All three were aged 8 to 10 years at the time of the initial injury, had suffered recurrent ankle sprains and had well localised and consistent tenderness precisely at the site of the anomalous ossific centre. All their symptoms were relieved by excision of the ossicle with reconstitution of the fibular collateral ligament. Whilst a separate secondary centre of ossification at the lower fibula is present in 1% of healthy children between the ages of 6 and 12 years, the condition described is extremely uncommon. Excision of the fragment should be reserved for those patients with recalcitrant symptoms and with consistent tenderness precisely at the site of the accessory ossicle

Injuries to the ankle are common in children. We investigated whether decreased dorsiflexion predisposes to such fractures and sprains. Passive dorsiflexion in children with ankle injuries was compared with that in a control group of patients with a normal ankle. The uninjured side was examined to determine flexibility in those patients with ankle injuries. In 82, the mean dorsiflexion was 5.7° with the knee extended and 11.2° with the knee flexed. In 85 controls, the mean dorsiflexion was 12.8° with the knee extended and 21.5° with the knee flexed (p < 0.001, Student’s t-test). There was a strong association between decreased ankle dorsiflexion and injury in children. A flexible triceps surae appeared to absorb energy and protect the bone and ligaments, while stiffness predisposed to injury. We suggest that children with tight calf muscles should undergo a regimen of stretching exercises to improve their flexibility

Objective: To ascertain the epidemiology of ankle injuries in elite youth football. Design: Retrospective analysis of prospectively collected injury data from English Football Association Academies. Setting: Forty-one FA Football Academies, between 1998 and 2006. Participants: For the complete seasons studied, a total of 14776 players were registered from U9 to the U16 age category – a mean of 2463 players per year. All ankle injuries of sufficient severity to miss 48 hours or more training were studied – 2563 injuries in total. Main outcome measurements: The incidence and burden of ankle injuries in this population, and factors associated with injury. Results: There was a mean incidence of one ankle injury per player per year, and a mean of 20 training days and 2 matches were missed per ankle injury. Increased injury rates were seen in older players, in competition and later in each half of match time. Peaks in injury were observed early in the season and after the winter break. In competition, more injuries were associated with a contact situation than in training. Eighty-eight injuries (3.4%) required a lay-off of three months or more and in 18 (0.7%) cases, the player failed to return to training. In total, 52290 training days and 5182 match appearances were lost through ankle injury. The majority of injuries were sprains, but more severe injuries occurred accounted for 3.9% of the total. Conclusions: Ankle injuries are common in young football players, and are often severe, with prolonged loss of training time. This has potential far reaching implications, both on and off the field. Further syudy in this area is suggested

We studied the late outcome of 40 ankles (from a consecutive series of 42) treated by a modified Evans procedure. The peroneus brevis tendon was used to fashion a static tenodesis. All the patients had suffered from persistent lateral instability following an ankle sprain. The follow-up period was between nine and 12 years. Excellent or good results were achieved in 33 ankles (82.5%), three had a fair result, and four were poor. The clinical results were matched by the radiographic results which showed significant talar tilt or anterior talar translation in only three ankles. The functional result showed no positive correlation with the stress-radiographic analysis. We concluded that this modification of the Evans operation gives satisfactory long-term results, which show little change from the good results at 24 to 35 months reported in an earlier paper from our department

1. Forty-two previously asymptomatic patients presenting with a recent rupture of the lateral ligament of the ankle, and twenty similar patients with a simple sprain of this ligament, have been followed for one year. The physical and radiological findings upon the completion of treatment have been related to functional instability of the foot one year later. 2. Persistent mechanical varus instability of the talus in the ankle mortise was a possible cause of functional instability one year after injury in four (or perhaps six) patients. 3. Adhesion formation was a possible cause of functional instability in one patient. 4. Seventeen patients finally displayed no clinical or radiological abnormality after injury, but noted functional instability of the foot one year later. 5. It is concluded that the pathological process which is usually responsible for functional instability of the foot after a lateral ligament injury is at present unknown

The Royal Marines regularly deploy to Norway to conduct Cold Weather, Arctic and Mountain Warfare training. A total of 1200 personnel deployed to Norway in 2010 over a 14-week period. Patients, whose injuries prevented them from continuing training, were returned to the UK via AEROMED. The aim of this investigation was to describe the epidemiology of musculoskeletal injuries during cold weather training. All data on personnel returned to the UK was prospectively collected and basic epidemiology recorded. 53 patients (incidence 44/1,000 personnel) were returned to the UK via AEROMED. 20/53 (38%) of cases were musculoskeletal injuries (incidence 17/1000 personnel). 15/20 musculoskeletal injuries were sustained while conducting ski training (incidence 13/1,000): 4/20 were non-alcohol related injuries, 1/20 was related to alcohol consumption off duty. Injuries sustained whilst skiing: 5/15 sustained anterior shoulders dislocation, 5/15 Grade 1-3 MCL/LCL tears, 2/15 sustained ACJ injuries, 1/15 crush fracture T11/T12, 1/15 tibial plateau fracture and 1/15 significant ankle sprain. Non-Training injuries: 1 anterior shoulder dislocation, 1 distal radial fracture, 1 olecranon fracture, 1 Scaphoid Fracture and one 5th metatarsal fracture. 60% of injuries were upper limb injuries. The most common injury was anterior shoulder dislocation 6/20 (Incidence 5/1000). Our results suggest that cold weather warfare training has a high injury rate requiring evacuation: 4% of all people deployed will require AEROMED evacuation, and 2% have musculoskeletal injuries. Ski training causes the majority of injuries, possibly due to the rapid transition from non-skier to skiing with a bergen and weapon. Military Orthopaedic and rehabilitation units supporting the Royal Marines, should expect sudden increases in referrals when large scale cold weather warfare training is being conducted. Further research is required to see if musculoskeletal injury rates can be decreased in cold weather warfare training

There is ambiguity concerning the nomenclature and classification of fractures of the ring of the second cervical vertebra (C2). Disruption of the pars interarticularis which defines true traumatic spondylolisthesis of C2, is often wrongly called a pedicle fracture. Our aim in this study was to assess the influence of asymmetry on the anatomical and functional outcome and to evaluate the criteria of instability established by Roy-Camille et al. We studied the plain radiographs and CT scans of 24 patients: 13 were judged to be asymmetrical, ten were considered unstable and 14 stable. Treatment was with a Minerva jacket in 15 fractures and by operation in nine. Surgery was undertaken in patients with severe C2 to C3 sprains. One patient with an unstable lesion refused operation and was treated conservatively with a poor radiological result. Our study showed that asymmetry of the fracture did not affect the outcomes of treatment and should not therefore influence decisions in treatment. The criteria of Roy-Camille seem to be reliable and useful. We prefer the posterior approach to the cervical spine, which allows both stabilisation of the fracture and correction of a local kyphosis

Background: Ankle sprains are common with the majority resolving with simple measures. Some patients may have residual pain and instability caused by functional instability. Intraarticular scar formation has been implicated in these patients. Few studies have shown the effectiveness of arthroscopic procedure in treatment of this condition. Aim: Our aim was to assess the role of arthroscopy in functional instability of the ankle. Methods: We performed retrospective analysis of case-notes of patients who presented with functional ankle instability from 2005 – 2007 who had failed a trial of conservative therapy and who had ankle arthroscopy, provided there was no true instability as determined by EUA and stress xrays. Results: Out of 77 patients with a mean age of 38.1, 5 patients had true mechanical instability. They underwent open repair of the lateral ligaments and were excluded from the study. 21 had steroid injections which gave temporary improvement in 11 of them but eventually all of the 72 remaining stable patients underwent ankle arthroscopy. 67 (76.7%) had significant amounts of scar tissue present which needed debridement, most commonly in the antero- lateral corner (58.3%). 52 patients improved (72.2%), 20 patients (27.8%) did not improve. 2 patients suffered a superficial wound infection. 17 patients had an osteochondral talar lesion. Of these, 14 patients improved, 2 did not and 1 patient did not attend follow up. Outcome: Our study supports the role of arthroscopy in the treatment of functional ankle instability resistant to conservative treatment. Significant improvement in symptoms can be expected in about 70% of patients following arthroscopic debridement of scar tissue rising to approximately 90% if there is an associated talar osteo-chondral lesion. Ankle arthroscopy is associated with a low complication rate and should be offered to patients with functional instability when conservative measures have failed especially if an osteochondral lesion has been identified

After a severe ankle sprain the incidence of residual complaints, particularly on the medial side of the joint, is high. We studied a consecutive series of 30 patients who had operative repair of acute ruptures of lateral ligaments. During operation, arthroscopy revealed a fresh injury to the articular cartilage in 20 ankles, in 19 at the tip and/or anterior distal part of the medial malleolus as well as on the opposite medial facet of the talus. In six patients, a loose piece of articular cartilage was found. We conclude that in patients with a rupture of one or more of the lateral ankle ligaments after an inversion injury, an impingement occurs between the medial malleolus and the medial facet of the talus. Patients with a lesion of the lateral ankle ligament caused by a high-velocity injury (a faulty landing during jumping or running) had a higher incidence of macroscopic cartilage damage (p < 0.01), medially-located pressure pain (p = 0.06) and medially-located complaints at one-year follow-up (p = 0.02) than those with a low-velocity injury (a stumble)

Anterior bony impingement of the ankle is a common cause of chronic ankle pain, and it represents an important indication to arthroscopic treatment. The purpose of the study was to analyze the factors affecting the clinical outcome of surgical treatment and to describe a new classification based upon the arthroscopic assessment, considering prognostic factors and rationale for treatment. 84 consecutive patients with a mean age of 32.6 years were treated between 2000 and 2005. The impinging lesions were divided into localized (antero-medial, antero-lateral and syndesmotic) or diffuse. The status of the chondral layer (A – Normal; B – Focal ICRS grade I–II; C - Focal ICRS grade III–IV; D – Diffuse ICRS grade I–II; E – Diffuse ICRS grade III–IV) was documented, as well as the presence of altered foot morphology (cavus or flat) or ligament lesions. Previous traumas or surgery were considered. Patients were evaluated after a 24–87 months follow-up, following the AOFAS scale. The pre-operative AOFAS score was 39.4, while at follow-up it scored 80.1(p< 0.05). Patients with diffuse anterior impingement obtained the best result in terms of improvement. Patients with normal cartilage had a better outcome but among cartilage lesions the better improvement was obtained in patients with diffuse severe cartilage damage. Associated regenerative treatment for focal chondral grade III–IV lesions provided the better results. Patients with associated surgically repaired ligament lesions had the better clinical outcome with respect to intact ligaments. On the basis of the results we purpose a new classification, based upon the prognostic factors, into 2 types: I – Localized; II - Diffuse. Further classification was made into subtypes A to E according to the associated chondral lesions. Finally the presence of associated conditions such as ligament lesions, previous sprains or surgery was considered, being relevant as prognostic factors

Aims

The primary aim of this study was to assess if traumatic triangular fibrocartilage complex (TFCC) tears can be treated successfully with immobilization alone. Our secondary aims were to identify clinical factors that may predict a poor prognosis.

Scaphoid fractures are commonly seen fractures following distal radius fractures, yet its diagnosis can be difficult. The present study is to explore the diagnostic approach to suspected scaphoid fractures in a district general hospital in the UK. This is a retrospective study. 286 Suspected scaphoid injuries were seen in our Fracture clinics. 184/286 were known to have normal x-ray findings initially and repeat x-ray in 10 days time. They were all treated as a simple case of a sprained wrist. 40 Patients out of the remaining 102 patients were noted to have scaphoid fractures on follow up x-rays and accordingly treated with cast. The remaining 62 patients were considered for further imaging. 28/102 went for bone scan, which confirmed scaphoid fracture in 4/28 cases. It also picked up other degenerative pathology in 4/28 cases. The rest of the scans were normal. 22/102 Were sent for CT scan which identified the fracture in 20 cases. CT scans provided details about the configuration of fracture, level of healing etc. MRI was performed in 12/102 cases, which confirmed fracture in 2/12 cases and bone bruising in 2/12 cases. There is no consensus regarding the investigation of choice when a follow up scaphoid x-ray is inconclusive in diagnosing a possible scaphoid fracture. In this study we note that a bone scan does not offer much information. On the other hand MRI and CT investigations were useful. We recommend the use of an MRI investigation for a fresh injury, and a CT scan for fresh and old injuries

Aims

COVID-19 remains the major focus of healthcare provision. Managing orthopaedic emergencies effectively, while at the same time protecting patients and staff, remains a challenge. We explore how the UK lockdown affected the rate, distribution, and type of orthopaedic emergency department (ED) presentations, using the same period in 2019 as reference. This article discusses considerations for the ED and trauma wards to help to maintain the safety of patients and healthcare providers with an emphasis on more remote geography.

1. The results of three forms of treatment (mobilisation, immobilisation for six weeks, and suture with immobilisation for six weeks) for ruptures of the lateral ligament of the ankle have been compared in previously uninjured asymptomatic patients. 2. Only suture and immobilisation ensured final mechanical stability of the ankle as assessed by stress radiography. Unstable ankles were found after both mobilisation and immobilisation, but in these groups no ankle finally displayed more than 8 degrees of relative talar tilt. 3. The mean duration of disability in patients who finally became symptom-free was: after mobilisation, twelve weeks; after immobilisation, twenty-two weeks; and after suture and immobilisation, twenty-six weeks. 4. One year after injury 58 per cent of patients treated by mobilisation, 53 per cent of patients treated by immobilisation, but only 25 per cent of patients treated by suture and immobilisation, had become perfectly symptom-free. 5. For these reasons, and because simple sprains are satisfactorily treated by mobilisation, it is suggested that mobilisation may be the treatment of choice for most, perhaps all, ruptures of the lateral ligament of the ankle

Introduction. Ottawa ankle rules originally described in 1992 have been shown to improve the pick-up rates of ankle fractures and avoid the need for unnecessary X-rays, thus minimising cost and radiation to the patient. We decided to carry out an audit at our hospital to look at the pick-up rates of ankle fractures and ways to minimise x-rays for the patient both in A&E and in the orthopaedic department. Methods. Ankle x-rays of 1088 trauma patients over a 7 month period from Dec 2009 to June 2010 (inclusive) were reviewed. Patients with ankle fractures were classified according to Weber type, and whether they were treated surgically or non-operatively. Non-operatively treated ankle fractures then formed the main sub-group of our study, looking at the number of follow-up X-rays and the amount of subsequent displacement. The amount of displacement was classified into non-displaced (0 mm), minimally displaced (<2mm) and displaced (>2 mm). Results. 171 patients (out of 1088) were found to have fractured their ankle giving a pick up rate of 16%. (cf a pickup rate of 26% described in literature with implementation of Ottawa rules). The pick up rate fluctuated each month from 31% in December to a meagre 6% fractures in June and this could be due to summertime sports injuries causing less fractures and more sprains. We noted a third more x-rays were ordered in Spring than Winter. There were no changes in junior staff in either the A&E or the orthopaedic department to account for the monthly variations. Conservatively managed fractures were followed up in the fracture clinic (n = 95, 56%) 16% (n = 11) of the conservatively managed patients were classified as Weber A fractures 84% (n=58) as Weber B fractures. No Weber C fractures were conservatively managed. Of the eleven Weber A fractures only one was minimally displaced. Conservatively managed Weber A fractures received an average of 1.36 x-rays on follow up in the Orthopaedic department. Of the Weber B fractures 42 were non-displaced whilst 16 were minimally displaced, and these received an average of 3.23 x-rays on follow up. None of these progressed to displacement > 2mm. Conclusion. Based on our audit, we have introduced a policy to limit the number of follow-up of X-rays for minimally displaced and undisplaced Weber A & B fractures to one. We have also re-emphasized the importance of Ottawa rule implementation in our A&E department

Aims

This is a multicentre, non-inventor, prospective observational study of 503 INFINITY fixed bearing total ankle arthroplasties (TAAs). We report our early experience, complications, and radiological and functional outcomes.

AIM: The purpose of this retrospective study was to assess the results of a novel surgical technique for chronic lateral ankle instability using dynamic extensor digitorum brevis (EDB) muscle transfer. METHODS: 15 patients underwent dynamic EDB muscle transfer for symptomatic chronic lateral ankle instability. All patients were quite fit and physically very active. 9 male and 6 female patients, mean age 27 (range, 22–32) were operated by single surgeon (ALP) between March 2003 and August 2005. All patients had standard procedure involving proximal transfer of the origin of EDB muscle whilst preserving its neuro-vascular pedicle. All patients went through a standard post-operative physiotherapy protocol including pro-prioceptive training. Mean follow-up was 24 months (range, 12–36 months). The mean functional Karlsson scores improved from 26.5 before surgery to 86.5 at 12 months after surgery. At follow-up, all patients had normal range of ankle movements and were functionally stable. All patients regained their pre-injury activity level at 12 months after surgery. There were no early or late complications in our series. DISCUSSION: Ankle sprains are the most common injuries sustained during sports and physical exercise. Treatment is usually conservative because most of these injuries heal without consequence. However, symptomatic chronic lateral ankle instability is a difficult problem to treat and several surgical techniques have been described. EDB muscle not only acts as a dynamic substitute for the deficient ligament but also overcomes the problem of over-tightening of the ligament leading to restricted supination. CONCLUSION: Dynamic EDB muscle transfer is a safe, clinically effective and reliable surgical option for symptomatic chronic lateral ankle instability

We treated 43 acute tears of the calcaneofibular ligament by operation in 43 patients after subtalar arthrography. There were 22 men and 21 women with a mean age of 22.3 years (14 to 61). Anteroposterior (AP), lateral and oblique views were obtained with the foot in 45° of internal rotation and the ankle in the neutral position. Any communication or leakage to the ankle, tendon sheaths, subcutaneous tissue and sinus tarsi was recorded. We examined an oblique view of the microrecess along the interosseous ligament and an AP view of the lateral recess just under the distal end of the fibula. We also studied a control group of 27 patients with isolated injuries of the anterior talofibular ligament without rupture of the calcaneofibular ligament. The findings in the two groups were significantly different when examined for leakage to the ankle (p = 0.0002), to the peroneal tendon sheaths (p = 0.0347) and to the subcutaneous tissue (p = 0.0222), absence of the microrecess (p = 0.0055) and presence of the lateral recess (p = 0.0012). Many ankle sprains which involve tearing of the calcaneofibular ligament are accompanied by injuries of the subtalar joint. Combined injuries of the anterior talofibular ligament and calcaneofibular ligament, and isolated injury of the anterior talofibular ligament should be differentiated

Purpose: Fissures of the flexor hallucis longus, an exclusively clinical diagnosis, are often unrecognised. Imaging is not contributive. The purpose of this work was to detail the clinical signs leading to surgical exploration with tendon suture, the only effective treatment. Material and methods: Lesions of the flexor hallucis longus, generally subsequent to ankle sprains resulting from trauma involving the medial border of the foot or from a fall, were found in the retrotalar gutter (1 patient), at the Henry node, the pulley of the common flexors and the flexor hallucis longus under the navicular bone (6 patients). Palpation produced exquisite pain. Pain was also provoked by movement of the great toe, explaining why the patients were unable to run or stand tiptoed. Ultrasound and MRI were negative. Surgery was peformed because of the persistent pain which did not respond to medical treatment (anti-inflammatory drugs, corticosteroid injections, plantar orthesis maintaining the medial vault, plaster cast). Surgical repair relieved pain in all cases and enabled renewed activities within three months on average. The treatment consisted in suture of the tendon associated with regularisation of the retrotalar gutter as needed and, at the subnavicular level, section of the Henry node and anastomosis of the flexors. Cast immobilisation was recommended for four to six weeks. Conclusion: In patients complaining of pain of the posterior crossway or in the subnavicular region, examination of the flexor hallucis longus should be undertaken to search for a fissure which requires surgical tendon repair. It is hoped that improved imaging techniques will provide a means of confirming the diagnosis before surgery

Purpose: Description of the types of injuries occurring in ‘’semi-professional’’ soccer players, analysis some factors influencing the occurrence and registration of treatment’s options. Material & Method: Between 1999–2003, 112 males semi-professional soccer players of different levels of skill, aged 16–38 (average: 28,4yrs) sustained 128 injuries during games or practice. Previous injuries, frequency of playing soccer weekly and options of treatment were also registered. Results: 89% of injuries caused by trauma and 11% by overuse. 68% of injuries involved the lower extremity, 21% the upper extremity, 7% both upper & lower extremity and 4% the spine. Joints sprains predominated (36%), followed by fractures (25%), menisci tears (12%), ligaments injuries (10%), e.t.c. More than 15 different injuries were treated. Injuries to the ankle were most prevalent (42%), followed by the knee (26%) and the wrist (17%). The 2/3 of the injured players were playing soccer ‘’occasionally’’ (no more than 1–2 times per week, usually without any previous training), while the 1/3 had suffered previous injury in the same area of their body. 45% of injured players were > 30yrs old. Most injuries occurred during games. The treatment was surgically or conservatively (in ratio 1:1), depending on the type of injury. Conclusions: Soccer players sustained a variety of injuries. Poor physical condition (occasionally playing & practicing), and ‘’personal’’ factors (previous injuries, level of skill) seemed to be related with the frequency and the severity of the occurred injuries. The treatment is based on the type of injury

To determine the type and number of injuries that occur during the training and practice of Muay Thai kick boxing and to compare the data obtained with those from previous studies of karate and taekwondo. One to one interviews using a standard questionnaire on injuries incurred during training and practice of Muay Thai kick boxing were conducted at various gyms and competitions in the United Kingdom and a Muay Thai gala in Holland. A total of 152 people were questioned, 132 men and 20 women. There were 19 beginners, 82 amateurs, and 51 professionals. Injuries to the lower extremities were the most common in all groups. Head injuries were the second most common in professionals and amateurs. Trunk injuries were the next most common in beginners. The difference in injury distribution among the three groups was significant (p≤0.01). Soft tissue trauma was the most common type of injury in the three groups. Fractures were the second most common in professionals, and in amateurs and beginners it was sprains and strains (p≤0.05). Annual injury rates were: beginners, 13.5/1000 participants; amateurs, 2.43/1000 participants; professionals, 2.79/1000 participants. For beginners, 7% of injuries resulted in seven or more days off training; for amateurs and professionals, these values were 4% and 5.8% respectively. The results are similar to those found for karate and taekwondo with regard to injury distribution, type, and rate. The percentage of injuries resulting in time off training is less

The Os subfibulare, or round ossicles at the tip of the lateral malleolus, are often regarded as accessory bone. Some patients with such fragments, however, complain of ankle pain and repeated sprain. This study addresses whether these fragments are unnecessary and ignorable?. Materials and method: From 1986 to 1998, we treated 54 ankles in 52 patients surgically. The average age at surgery was 18 years; the mean follow up period was 4.7 years. The whole the fragment was fixed to the lateral malleolus using a tension band. Results: Each fragment was attached to at least one ligament. We classified these attachments as follows:. Type I a: only ATFL was attached to one fragment. Type I b: ATFL and CF were attached to one fragment. Type I c: ATFL, CF, and PTFL were attached to one fragment. Type II : ATFL and CF were attached to two individual fragments. There were 7 Type I a, 37 Type I b, 6 Type I c, and 4 Type II. Fifty-one ankles (94%) developed bony union and three united fibrously. The talar tilt was restored from 9.8 to 4.7 degrees after surgery. The American Orthopaedic Foot and Ankle Societyñs clinical rating system for the ankle-hindfoot improved from 77 to 98 and ankle pain decreased dramatically. Conclusion: The fragment at the tip of the lateral malleolus is the origin site of the lateral ligaments. This fragment can be united with the lateral malleolus. We believe that the fragments are keystones of the lateral ankle ligament complex

Aims

Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°.