The purpose of this study was to review the total ankle arthroplasties performed in consecutive series of 78 ankles and to determine the short-term results in cases with over 12 months follow-up. Preoperative diagnoses were post-traumatic osteoarthritis in 40 ankles (51.3%), primary osteoarthritis in 32 ankles (41.0%), and systemic arthritis in six ankles (7.7%). HINTEGRA. ®. (Newdeal SA, Lyon, France) total ankle system was used in all cases. Fifty-five total ankle arthroplasties including four revision cases, followed up for over 12 months (range, 13~49 months) were included in this study. Ankles were divided into three groups according to the coronal plane deformity in preoperative standing ankle AP radiograph; Varus (≥10°; 20 ankles (39.2%)), neutral (< 10° varus or valgus; 25 ankles (49%)), and valgus (≥10° valgus; 6 ankles (11.8%)). Various additional surgeries were performed simultaneously with the arthroplasty to correct the deformities; deltoid ligament release (25 cases), posterior tibialis tendon lengthening (2 cases), peroneus longus tendon transfer to brevis (5 cases), lateral ankle reconstruction with modified Broström procedure (4 cases), lateral closed-wedge calcaneal osteotomy (3 cases), percutaneous heel cord lengthening (19 cases), and gastrocnemius recession (1 case). In one patient with severe valgus deformity, staged total ankle arthroplasty was conducted after primary triple arthrodesis. Preoperative and postoperative visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, range of motion (ROM), as well as patient’s satisfaction and willingness to receive the operation again were evaluated The results were compared among the three groups. Serial radiographs were reviewed for any radiological changes. AOFAS score has improved from 54.3 ± 11.4 pre-operatively to 79.2 ± 11.4 at last follow-up. VAS has decreased from 6.8 ± 1.6 to 3.2 ± 1.6. Mean improvement in ROM was 15.6 ± 16.2 degrees. Forty-eight cases (873%) were satisfied with excellent or good results and 49 cases (89.1 %) were willing to receive the operation again. No significant differences in the postoperative VAS (p=0.14), AOFAS score (p=0.79), and ROM (p=0.06) were found among the three groups. Hetero-topic ossifications were observed in 12 cases (23.5%) and periosteal reactions proximal to medial malleolus occurred in four cases (7.8%). Perioperative complications include one intraoperative medial malleolus fracture which was successfully managed with two cannulated-screws, and one medial malleolar stress fracture at six weeks after surgery which has healed spontaneously. One case with osteolysis around tibial screws was managed with bone graft. One case with deep fungal infection was converted to arthrodesis after infection control. Four ankles had to be revised including three cases of polyethylene bearing change due to dislocation, and one case of tibial component and bearing change due to loosening. The patient with revised tibial component was converted to arthrodesis due to recurred loosening. The Kaplan-Meier cumulative survival rate was 90.9% at 12 months and 87.8% at 49 months postoperatively. The short term clinical results of HINTEGRA ankles showed favorable results. No significant differences were observed among different groups of coronal plane deformities when adequate additional surgeries were performed simultaneously. Long term follow-up study is required

Aims

Treatment of Weber B ankle fractures that are stable on weightbearing radiographs but unstable on concomitant stress tests (classified SER4a) is controversial. Recent studies indicate that these fractures should be treated nonoperatively, but no studies have compared alternative nonoperative options. This study aims to evaluate patient-reported outcomes and the safety of fracture treatment using functional orthosis versus cast immobilization.

Objective

To evaluate early mobilization with the ‘STRONG regime’ is safe after lateral ankle ligament repair with suture tape augmentation.

We studied the merits of physical examination after inversion injury of the ankle in 160 consecutive patients. They had an explanatory operation if they had a positive arthrogram and/or positive signs on a delayed physical examination.

To determine the interobserver variation in delayed physical examination, five different examiners were asked to give independent assessment of the injury. Those with limited clinical experience produced more accurate results when physical examination was performed at five days after the injury, rather than within 48 hours.

The specificity and sensitivity of delayed physical examination for the presence or absence of a lesion of an ankle ligament were found to be 84% and 96%, respectively. The interobserver agreement for the delayed physical examination of the ankle was good (kappa values 0.5, 0.6, 0.6 and 1.0).

Delayed physical examination gives information of diagnostic quality which is equal to that of arthrography, and causes little discomfort to the patient.

Background

The recommended indications for total ankle replacement (TAR) are limited, leaving fusion as the only definitive alternative. As longer-term clinical results become more promising, should we be broadening our indications for TAR?

Ankle fractures account for 10% of all fractures. Most deformed looking ankles are manipulated in the emergency departments (ED) on clinical judgement in order to improve the outcome and avoid skin complications. It is accepted that significantly displaced ankle injuries with neurovascular (NV) compromise or critical skin should be reduced prior to imaging.

However, is it really possible to understand the injury to an ankle without an x-ray or other imaging? The other possible injuries around the ankle, presenting with swelling and deformity of the ankle region, may include a ligamentous, talar, subtalar, Chopart joint or calcaneal injury. Does the risk of waiting for the imaging outweigh the benefit of manipulation of an undiagnosed injury?

This prospective study involved the analysis of all patients with ankle injuries referred to orthopaedics between November 2009 and February 2010. Results: Over the audited period 100 referrals were identified (43 male, 57 female). The average age was 50.4 years (range 5–89). Only 2% of fractures were open. Manipulation in the ED was performed for 44% of patients. Of these, 39% (17 cases) were manipulated and supported in plaster slab without an initial x-ray; 3 due to vascular deficit, 2 due to critical skin and 12 with no documented reason!

Re-manipulation in the ED as well as definitive open reduction and internal fixation (ORIF) were significantly lower in those patients who had an x-ray prior to manipulation (p < 0.05). ORIF was performed in 68% of all patients. Importantly, 80% of ankles manipulated in ED went on to have ORIF which was significantly higher than the 47% in the non-manipulation cohort (p < 0.05).

We conclude that taking ankle injury radiographs prior to any attempt at manipulation, in the absence of NV deficit or critical skin, will constitute best practice.

Introduction: The objective of this study was to investigate the clinical, radiographic and subjective outcome after salvage arthrodesis for failed total ankle arthroplasty (TAA), with a focus on salvage in inflammatory joint disease (IJD).

Methods: Between 1994 and 2005, salvage arthrodesis for failed mobile-bearing TAA was performed in 18 ankles. Primary diagnosis was IJD 15 and osteoarthritis 3. Tibiotalar fusion was performed in 7 and tibiotalocalcaneal fusion in 11 ankles (in 9 out of these, the subtalar joint was already ankylosed). Serial radiographs were studied retrospectively by an independent observer for time to union. Clinical outcome at latest follow-up was measured by the AOFAS score, by the Foot function Index and by VAS scores for pain, function and satisfaction.

Results: Blade plates were used in 7 ankles, all united. Nonunion developed in 7 IJD ankles stabilized by either a nail or screws or multiple K-wires. Revision arthrodesis was done for 4 nonunions, 3 were successful. Eleven patients (8 fused ankles, 3 nonunions) were available for clinical evaluation. At follow-up, their mean AOFAS score was 62.4; mean overall FFI was 70.1; VAS for pain was 20.1, for function 64.3, for satisfaction 73.8.

Conclusions: Blade plate fixation is successful in salvage ankle arthrodesis. An high nonunion rate was found after salvage ankle arthrodesis in IJD with other methods of fixation. Several publications on primary arthrodesis also show an elevated nonunion rate in IJD. Clinical results were relatively good. The three non-unions in follow-up had subjective results similar to the fused ankles.

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

Introduction: Total ankle replacement is proving a reliable procedure for ankle arthrosis. Some authors have recommended that significant hindfoot deformity should be a contraindication. This study aims to provide guidance on the management of this difficult problem.

Methods: 170 consecutive total ankle replacements were performed in 147 patients, aged 32–83 (mean 65) between 1999 and 2006 by a single surgeon. All surviving patients (5 deaths) were followed up prospectively on an annual basis, for a mean of 3 years (1–8 years). Comparison was made between Group A (45 ankles with a hindfoot deformity of > 10° varus or valgus) and Group B (the remaining 120 ankles).

Results: There was no statistical difference between the 2 groups for age, sex or indication for surgery (osteoarthritis in 81%). Group A comprised 8 valgus and 36 varus ankles. 23/36 varus ankles had a deformity of > 20°.

6 revisions (13%) were performed in Group A (5 of these related to instability – all preoperatively varus of > 20 degrees). 10 revisions (8%) were performed in Group B (2 related to instability).

6 ankles underwent intra-operative deltoid release and 6 had pre or post-operative calcaneal osteotomy. Only one of these required revision for instability. 4 ankles underwent post-operative lateral ligament reconstruction. These ankles all failed due to instability.

The mean postoperative American Foot and Ankle Society score in Group A was 85, compared to 78 in Group B.

Discussion: Our study reveals that patients with significant hindfoot deformity may benefit from total ankle replacement. However, the risk of revision due to instability and need for further surgery is higher, especially with a varus deformity of > 20°. Almost a quarter of these ankles required revision. Potential solutions may be to correct the deformity with additional calcaneal osteotomy or medial release, whereas lateral ligament reconstruction alone is inadequate.

Aims: This study reports the mid-term results of a prospective series of 200 ankle replacements using the Scandinavian Total Ankle Replacement (STAR). 105 patients were more than five years since surgery.

Method: 200 patients; 85 male, 115 female; mean age 60 years (18–83) underwent primary replacement. The mean follow-up was 54 months (4–110). The diagnosis was inflammatory joint disease (IJD) for 119 patients and osteoarthritis (OA) for 81.

Results: 144 patients had a good outcome and uncomplicated recovery. A further 18 patients had a complication, which resolved with non-operative treatment (three prolonged wound healing, 15 malleolar fractures, either at surgery or at a later date). A further eight patients were clinically satisfactory but the x-rays showed adverse features (five aseptic loosening and three recurrent deformity). Five patients have a poor outcome due to persistent pain and stiffness but have not required further surgery. A further nine patients had a complication necessitating surgery (three calcaneal osteotomy and lateral ligament reconstruction, one tibial osteotomy to improve alignment, one autogenous bone graft for osteolysis, one for late medial malleolar fracture, one split skin graft for delayed healing, two for removal of heterotopic bone). At two years the AOFAS score for pain improved from 0 to 35 (maximum 40) and the functional score from 28 to 35 (maximum 60). There were 16 total failures that required fusion (11) or revision (five). The causes were nine aseptic loosening, three recurrent deformity, two fracture malleolus, one deep infection, one persistent pain. The cumulative five-year survival rate was 89% (95% CI 81% to 96%), with time to decision to revision or fusion as the endpoint.

Conclusions: There was no difference in survival between ankle replacement for OA or IJD. Ten out of the 16 failures occurred early (< two years), which we attribute to technical error or attempting replacement of ankles with severe deformity. The failure rate after two years is approximately 1% per annum.

This study seeks to determine the additional cost involved in the management of patients requiring operative fixation of their fractured ankle but whose operation is delayed more than 24 hours.

87 consecutive patients presenting acutely with a fractured ankle that required an operation during a single year were included in the study. All patients with ankle fractures referred from other centres, open fractures and ankle fractures whose non-operative management had failed were excluded from the study. 79 patients presented within 24 hours of their injury and so were eligible for early operative intervention. Of these, 74 presented within 6 hours of injury. Only 47 (60%) of the patients were operated on within 24 hours of their injury. Similarly, 11 (61%) of the 18 patients with trimalleolar fractures were operated on within 24 hours. Patients whose operations were delayed spent an average 4. 4 days more as an inpatient. This was statistically significant (p< 0. 0001, Wilcoxon signed rank test). The postoperative stay of patients having delayed operations was also statistically more than those undergoing early operation, (p< 0. 0001). The cost of the additional stay was calculated at £225/day/patient and equalled £39, 600 for the 40 patients whose operations were delayed.

We believe that the operative management of ankle fractures should be given special consideration. These injuries are such that they offer an initial limited window of opportunity for operative intervention (within 24 hours of injury). If this opportunity is missed, then the patient’s operation may have to be delayed for clinical reasons. In our study, only 60% of patients underwent early operative fixation of their fracture; a figure that can surely be improved upon. Therefore, we conclude that significant savings could be accrued by hospitals adopting protocols to fast-track pre-operative interventions to achieve early operation (within 24 hours) unless contraindicated.

Aims: To determine the clinical, radiological and sur-vivorship results of a series of 200 cementless STAR total ankle replacements. Methods: 200 consecutive total ankle replacements were prospectively entered into the study. There were 119 with inßammatory joint disease and 81 with osteoarthritis. Mean follow up was 46 months (24 to 101). No ankles were lost to follow up for reasons other than patient death. All ankles were clinically assessed with AAOFAS scores and radiologically assessed within a year of the results being analysed. Results: Fouteen ankles were revised or fused. Eight ankles required further surgery to resolve a complication. The cumulative survival rate at 5 years was 92.7% using time to decision to revise or fuse the joint as the endpoint. The most frequent complications were wound healing problems and malleolar fracture. This became less common as experience was gained. Conclusions: These midterm results are promising but the authors do not advocate ankle replacement in all those with degenerative disease of the ankle

Survivors of infantile meningococcal septicaemia often develop progressive skeletal deformity as a consequence of physeal damage at multiple sites, particularly in the lower limb. Distal tibial physeal arrest typically occurs with sparing of the distal fibular physis leading to a rapidly progressive varus deformity. Isolated case reports include this deformity, but to our knowledge there is no previous literature that specifically reports the development of this deformity and potential treatment options.

We report our experience of 6 patients (7ankles) with this deformity, managed with corrective osteotomy using a programmable circular fixator.

Introduction: Screws placed in the fibula do not have a satisfactory purchase during internal fixation of an osteoporotic ankle fracture. Tibia-pro-fibula screws that extend from the fibula into the distal tibial metaphysis provide additional purchase. The purpose of this study is to investigate if purchase of these screws can be enhanced further by injecting calcium sulfate and calcium phosphate composite graft in the drill holes prior to insertion of the screws.

Methods: Bone density was quantified using DEXA scan in paired cadaver legs. One leg from each pair was randomly selected for injection of composite graft into screw holes before insertion of the screws. Two screws were inserted through the fibula into the distal tibial metaphysis in each leg, at the level of the syndesmosis under fluoroscopy in a standardized fashion using a jig.

The screws were pulled out using a materials testing machine. Stiffness, force, displacement, and energy required were recorded.

Results: After testing 4 pairs of cadaver legs, a statistically significant difference was noted in displacement, failure load, and failure energy between augmented and non-augmented screws, with the augmented screws being considerably stronger. Of the two screws the distal, when compared to the proximal one, required more displacement, higher force and energy to fail whether augmented with composite graft or not.

Conclusion: Screws augmented with composite graft provide significantly greater purchase in an osteoporotic distal tibial metaphysis than non-augmented screws.

Clinical relevance: Use of composite graft to augment purchase of the screws inserted in the distal tibial metaphysis may enhance the stability of the internal fixation of an osteoporotic ankle fracture. This will enable early weight-bearing mobilization and return to function which is important in elderly patients.

Aims: To evaluate the inßuence of wobble board training on complaints and on the control of ankle motion in functionally unstable ankles during a sudden inversion in the standing position. Methods: 25 patients were randomly allocated to a training group (13 persons, 15 ankles), or to a control group (12 persons, 15 ankles). Patients were only included if they suffered invalidating disabilities following at least two ankle inversion trau-mañs followed by at least 6 weeks of rehabilitation. They were randomly allocated to a wobble board training group (6 weeks), or to a no intervention control group. Accelerometric and electromyographic analysis of functional control during a sudden ankle inversion of 50û in the standing position and a validated functional impairments index were used to assess efþcacy. Results: Trained patients with Òmedium latencyÒ reßexes (n= 5) showed signiþcantly earlier decelerations with the ankle displaying in a signiþcantly smaller inversion displacement (p< 0.05, power=0.96). Trained patients with Òshort latencyÒ reßexes (n= 10) showed no signiþcant change in inversion control. All trained patients showed signiþ cantly less impairments compared to the control group. Conclusions: These results support the treatment strategy that wobble board training should be included in the rehabilitation of functional ankle instability.

Survivors of meningococcal septicaemia often develop progressive skeletal deformity secondary to physeal damage at multiple sites, particularly in the lower limb. Distal tibial physeal arrest typically occurs with sparing of the distal fibular physis leading to a rapidly progressive varus ankle deformity. There is no previous literature reporting this ankle deformity following meningococcal septicaemia.

We report the management of this deformity in 13 ankles in 10 consecutive patients 36 months after meningococcal septicaemia. Plain radiographs and MRI were used to define the deformity and the extent of growth plate involvement.

The Taylor Spatial Frame (TSF) with a distal tibial metaphyseal osteotomy was used to restore the distal tibio-fibular joint. Distal fibular epiphysiodesis was performed in all ankles at the initial procedure. Distal tibial epiphysiodesis was performed at the time of fixator removal.

The age at operation ranged from 3–14 years (mean 8). The preoperative ankle varus deformity ranged from 9–29 degrees (mean 19). The differential shortening of the tibia with respect to fibula was on average 1.2 cms. The mean time in frame was 136 days. After a mean follow-up of 1.7 years results were excellent in all patients with complete correction of deformity and shortening. Mechanincal axis was corrected in all patients.

Complications included, 4 superficial pin site infections, 1 lateral peroneal nerve palsy which recovered completely. There were no major nerve or vascular complications.

We consider that this approach provides a powerful method of correction for this difficult group of patients.

Background: Stress radiography and more recently magnetic resonance imaging have been used to study the integrity of lateral ankle ligaments in chronic symptomatic instability after injury.

Aim: Our aim was to see if magnetic resonance imaging was as good as examination under anaesthesia and stress radiography, for diagnosing injury to the lateral ankle ligaments.

Study Design: Cross-over study.

Methods: Fifty eight patients, 47 men and 11 women, were included in the study. These were athletes or military personnel with symptomatic instability of the ankle after injury. This cohort of patients had MRI scans, stress radiographs and arthroscopic treatment of their ankle. Integrity of the calcaneo-fibular ligament (CFL) was recorded arthroscopically. The sensitivity, specificity, positive and negative predictive value of MRI and stress views, in assessing integrity of the CFL, were compared against the arthroscopic findings which was considered to be the gold standard.

Results: Stress radiography under anaesthesia and MRI has sensitivities of 94% and 47% and specificities of 98% and 83% for diagnosing injury to the CFL, respectively. Stress radiography has a higher accuracy in diagnosing CFL injuries as compared to MRI.

Conclusion: The results of this study casts doubt on the efficacy of MRI in the diagnosis of serious ankle ligament injuries.

Introduction. A subset of patients in cast awaiting fixation of ankle fractures require conversion to delayed external fixation (dEF). We aimed to evaluate the effect of delayed versus planned external fixation (pEF), then identify objective characteristics contributing to need for conversion. Method. We extracted data from our booking system to identify all ankle external fixation procedures between 2010 to 2022. Exclusions included open fractures, the skeletally immature, and pilon or talus fractures. Fractures were classified using the AO/OTA classification, then a matched cohort was identified based on fracture classification. We compared the planned, delayed and matched cohorts for demographics, posterior malleolar fragment (PMF) ratio, and degree of displacement at presentation. Results. We identified 25 pEF, 42 dEF, and 67 matched patients. Ankles with dEF had a 3.8 day longer time to ORIF from presentation than those who had pEF, and had an infection rate of 9.5%, compared to 4% in the pEF group. Two patients in the dEF group required further operative intervention. There were no infections or reoperations required in the pEF or matched groups. The dEF group were more likely to have ≥2 reductions (OR 4.13), a PMF ratio of >0.23 (OR 5.07), and have increased displacement at time of injury on lateral (32% vs 19%) and AP (62% vs 36%) radiographs. Discussion. Our retrospective study highlights the longer time to operation and increased infection rates of patients who do not get timely external fixation. We propose a series of objective parameters that predict failure of cast treatment and guide the surgeon to consider planned external fixation in some ankle