Introduction

Deltoid ligament reconstruction (DLR) is an important factor in the consideration of pes planus deformity. There is little evidence in the literature determining whether DLR could mitigate the risk of patients acquiring flat foot postoperatively following deltoid ligament injury.

Background

Ankle fractures associated with diabetes experience more complications following standard Open-Reduction-Internal-Fixation (ORIF) than those without diabetes. Augmented fixation strategies namely extended ORIF and hind-foot-nail (HFN) may offer better results, and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes including early post-operative weight bearing and surgical complications.

Introduction

The management of open or unstable ankle and distal tibial fractures pose many challenges. In certain situations, hindfoot nailing (HFN) is indicated, however this depends on surgeon preference and regional variations exist. This study sought to establish the current management and outcomes of complex ankle fractures in the UK.

Background

Studies have compared open reduction internal fixation (ORIF) with fibular nail fixation (FNF) and shown reduced wound complications with minimal difference to PROMS in the short term. Our aim is to compare long-term outcomes for unstable ankle fractures at 10 year follow up.

Introduction

Hindfoot intramedullary nail fixation (HFN) or fibula pro-tibial screw fixation (PTS) are surgical options for ankle fractures in patients with multiple co-morbidities; we compared their outcomes.

Background

In fixation of the fibula in ankle fractures, AO advocate using a lag screw and one-third tubular neutralisation plate for simple patterns. Where a lag screw cannot be placed, bridging fixation is required. A local pilot service evaluation previously identified variance in use of locking plates in all patterns with significant cost implications. The FAIR study aimed to evaluate current practice and implant use across the United Kingdom (UK) and review outcomes and complication rates between different fibula fixation methods.

Background

There is an increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. In our previous multicenter study (Powell, BOFAS 2016) we showed that the Olerud-Molander Ankle Score (OMAS) was 79 for unimalleolar fractures and 65 for bi malleolar fractures, however it dropped significantly to 54 in trimalleolar fractures. In creating a treatment guiding classification, we report our results in a system change in management of posterior malleolar fractures in our unit.

In this retrospective cohort study, we analysed the incidence and functional outcome of a distal tibiofibular synostosis. Patients with an isolated AO type 44-B or C fracture of the ankle who underwent surgical treatment between 1995 and 2007 were invited for clinical and radiological review. The American Orthopaedic Foot and Ankle Society score, the American Academy of Orthopaedic Surgeons score and a visual analogue score for pain were used to assess outcome.

A total of 274 patients were available; the mean follow-up was 9.7 years (8 to 18). The extent of any calcification or synostosis at the level of the distal interosseous membrane or syndesmosis on the contemporary radiographs was defined as: no or minor calcifications (group 1), severe calcification (group 2), or complete synostosis (group 3).

A total of 222 (81%) patients were in group 1, 37 (14%) in group 2 and 15 (5%) in group 3. There was no significant difference in incidence between AO type 44-B and type 44-C fractures (p = 0.89). Severe calcification or synostosis occurred in 21 patients (19%) in whom a syndesmotic screw was used and in 31 (19%) in whom a syndesmotic screw was not used.(p = 0.70). No significant differences were found between the groups except for a greater reduction in mean dorsiflexion in group 2 (p = 0.004).

This is the largest study on distal tibiofibular synostosis, and we found that a synostosis is a frequent complication of surgery for a fracture of the ankle. Although it theoretically impairs the range of movement of the ankle, it did not affect the outcome.

Our findings suggest that synostosis of the distal tibiofibular syndesmosis in general does not warrant treatment.

Cite this article: Bone Joint J 2015;97-B:945–9.

During surgical reduction of ankle injuries with syndesmotic instability surgeons often use the anteroposterior (AP) and mortise radiographs to assess reduction. Current literature predicts 50% are malreduced mainly in the sagittal plane. Our aim was to develop a radiographic measure based on the lateral view to assess both the normal and abnormal fibula/tibia relationship after simulated syndesmotic malreduction and to evaluate the effect on commonly used AP and mortise measurements.

Nine fresh-frozen cadaveric specimens were dissected to the level of the syndesmosis. AP, mortise and talar dome lateral radiographs were obtained before and following syndesmosis division and posterior fibula displacement. On the lateral radiograph a line was drawn (Orthoview) from the anterior border of the fibula bisecting a line drawn from the anterior to posterior lips of the distal tibia. The ratio of the anterior-posterior segments was calculated. Also a line was drawn from the posterior border of the fibula and the distance was measured to the posterior lip of the tibia.

At 0, 2, 4 and 6mm of displacement the ratio measured 1.3±0.2, 1.1±0.2, 0.9±0.2 and 0.7±0.2 respectively with all pairwise comparisons being significantly different. Inter- and intra-observer variability varied from substantial to perfect. The only significant medial clear space (MCS) difference was on the mortise view between 0mm (2.0±0.3mm) and 6mm (2.4±0.4mm) displacement.

Our new measure of syndesmotic reduction is reproducible and can detect from 2mm of saggital fibular displacement. At maximum fibular displacement the increase in MCS was less than 1mm. This demonstrates standard mortise radiographs are poor at detecting syndesmotic reduction. An interesting observation was in all specimens prior to any displacement, the posterior fibular line always bisected the posterior lip of the tibia or lay just anterior to it, never posterior. This could serve as a useful adjunct for surgeons when assessing syndesmotic reduction intra-operatively.

Introduction

Many common fractures are inherently stable, will not displace and do not require plaster casting to achieve union in a good position. Nevertheless, many patients with stable fractures are advised that they need a cast, despite the potential for stiffness, skin problems and thromboembolism. Attempts to challenge this practice often meet the argument that patients prefer a cast for pain relief. We analysed five years of a single consultant's fracture clinic to see how many patients with stable foot and ankle fractures chose a cast after evidence-based counselling.

Diabetes is a poor prognostic indicator after an ankle fracture. Many surgeons avoid operating due to concerns regarding complications.

We performed a retrospective analysis of complication rates for acute ankle fractures in diabetics with a control non-diabetic patient treated by all surgeons in our unit and assessed factors for success including long-segment fixation.

Patient records were cross-referenced with departmental databases and a review of all ankle fractures managed in our department was conducted from 2012. All patients subjected to a retrospective-review of their follow-up for at least 6-months. Radiographs were assessed of the ankle before and at completion of treatment being reviewed independently (RA & FR).

We identified the HB1Ac (diabetic-control) and systematic co-morbidities. Fractures were classified into unimalleolar, bi malleolar and trimalleolar and surgery grouped into standard or long-segment-rigid fixation.

Statistical analysis was conducted using absolute/relative risk (RR); numbers needed to treat (NNT) were calculated. We compared a control-group, a diabetic group managed conservatively, and undergoing surgery; comparing the concept of rigid fixation and prolonged imobilisation in isolation or combined.

Further sub-analysis conducted assessing diabetic neuropathy, retinopathy and nephropathy. Ethics approval was granted as per our institutional policy by our governance lead.

We identified 154 diabetic ankle fractures, seventy-six had conservative-treatment; 78 had operative fixation of which 23 had rigid-long-segment-fixation.

The diabetic-groups had a higher risk-relative-risk of complication − 3.2 (P< 0.03) being linked to systematic complications of diabetes e.g. neuropathy 5.8 (P< 0.003); HBA1c 4.6 P< 0.004); and neuropathy or retinopathy 6.2 (P< 0.0003).

Relative-risk reduction of complications occurred following surgery with prolonged immobilization (0.86) and rigid-fixation (0.65). The Number-Needed-to-Treat required to see a benefit from rigid fixation was 7.

Diabetics have a higher risk for complications, however the risk is not as great as previously reported. We provide evidence of rigid-long-segment-fixation with prolonged-immobilization improving-outcomes.

Introduction

Different techniques for fixation of lateral malleolus have been described. We report our results of using fibula rod for unstable ankle fractures in level one major trauma centre.

Introduction

The conservative management of stable Weber B fibula fractures remains variable. We thought that the current trend in our institution poses an unnecessary burden on fracture clinics.

Introduction

Post-traumatic arthritis is the commonest cause of arthritis of the ankle. Development of arthritis is dependent on the restoration of pre-injury anatomy. To assess the effect of grade of lead surgeon on the accuracy of surgical reduction, we performed a retrospective radiographic analysis of all ankle fractures undergoing open reduction and internal fixation, in a single institution.

Introduction

Operative fixation of ankle fractures is often deferred due to swelling to avoid the risk of wound problems. The routine practice is to admit the patient and operate once the swelling has subsided. We introduced a new pathway to manage these ankle fractures at home preoperatively to improve service efficiency. We studied the impact of home therapy on length of inpatient stay and associated problems.

The management of unstable ankle fractures is challenging due the difficulty in differentiating between stable and unstable fracture patterns. The aim of our study was to examine our practice and to determine if the operative management of unstable ankle fractures resulted in significantly improved radiographic parameters.

Between June 2008 and December 2008, we identified all skeletally mature patients who were diagnosed with an ankle fracture after having radiographs in the radiology department at our institution. We analysed the case notes and radiographs of these patients retrospectively. The fractures were classified according to the Weber and Lauge-Hansen classification. Radiographs were evaluated for shortening of the fibula, widening of the joint space, or malrotation of the fibula. Three measurements were used to ascertain whether the correct fibular length has been restored – the circle sign, the talocrural angle, and the tibiofibular (or Shenton) line.

Of 1064 patients who had radiographs, 123 patients sustained a fracture of the ankle. There were 61 females and 62 males, with a median age of 47 years. There were 20 Weber A, 80 Weber B and 12 Weber C ankle fractures. Eleven fractures could not be classified according to the Weber classification. According to the Lauge-Hansen classification there were 44 Supination-External rotation (SER) stage II fractures, 35 Supination-External rotation (SER) stage IV fractures, and 7 Pronation-External rotation (PER) stage III fractures. In the unstable SER stage IV fractures, 30 of the 35 patients had operative treatment and there was no statistically significant difference in the average Talocrural angles in the operative (78.9°) and nonoperative groups (83.4°). None of the patients with an SER stage IV fracture managed nonoperatively had an adequate circle sign compared to 14 of the 30 patients in the operative group who had an adequate circle sign. In the PER stage III fractures 4 of the 7 patients had operative treatment. The average Talocrural angle in the operative group was 79.1° versus 75.3° in the nonoperative group, with all patients in the operative group having an adequate circle sign compared to none in the nonoperative group. The patient numbers in the PER stage III group however were too small to show a statistically significant difference. In 4 patients with unstable fracture patterns, the use of a third tubular plate to bridge a fibula fracture without an inter-fragmentary lag screw led to inadequate restoration of fibular length in all cases.

It is important to recognise unstable ankle fracture patterns and, in patients treated operatively, to restore fibular length and rotation. Operative management of unstable SER stage IV and PER stage III ankle fractures can restore normal radiographic parameters. We highlight certain technical pitfalls in restoring fibular length such as the inappropriate use of the semi-tubular plate as a bridging plate.

Introduction:

Unstable ankle fractures are commonly treated with operative fixation. Isolated lateral malleolus fractures (Weber B) are often operated by orthopaedic trainees. Operative fixation of these fractures is included in the index procedures of procedure based assessment (PBA) of intercollegiate Surgical Curriculum Programme (ISCP). Orthopaedic trainees are expected to be competent in this procedure by the end of their training. Fluoroscopic guidance is essential for adequate reduction and safe fixation of these fractures.

A delay in operative intervention for ankle fracture in the presence of blistering at the operative site is generally considered to reduce problems with soft tissue complications including infection. No evidence exists to show an increased rate of complications. Previous work has characterised two types of blisters clear- and blood-filled. It has been suggested that the presence of a blood-filled blister confers a higher risk of wound healing complications compared with a clear-filled blister.

We present a series of patients who underwent surgery for ankle fracture, in the presence of blisters at the operative site, without any change to standard management of the fracture. We also present a review of the literature.

We prospectively followed six patients who underwent early internal fixation (no delay in surgical intervention) of ankle fracture in the presence of blisters at the operative site. In many cases the surgical incisions were made through the blistered skin. No patients had any additional treatment for their blisters. All patients were treated with the same postoperative protocol.

All six patients with both blister types went on to fracture union with no soft tissue complications and no cases of infection.

This initial observational study supports the treatment of ankle fractures with early internal fixation in the presence of soft tissue blisters at the operative site. It is possible that the stabilisation of underlying skeleton results in better healing of the skin and other soft tissues which is a concept often employed in the management of open fractures. We plan to carry out further prospective work on a larger number of patients as part of a randomized trial to confirm this finding.